Medical History Form - Adult Missions Ministry Team
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Medical History Form
Adult Missions Ministry Team
Date: __________________________
Name ____________________________________________________
Home Phone ___________________________
Address __________________________________________________
Business Phone ___________________________
Number, Street
City _______________________________________
State _________
Zip Code ____________________
Occupation _________________________________
Social Security Number _____________________________
Date of Birth ____________
Sex ____M ____ F
Weight _________
_____ Single
_____ Married
month/day/year
Name of Spouse ____________________________
Closest Relative ________________________
Phone _____________
If you are completing this form for another person, what is your relationship to that person? ________________________________
For the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be
considered confidential.
1.
Are you in good health?
Yes
No
2.
Has there been any change in your general health within the past year?
Yes
No
3.
My last physical exam was on:
4.
Are you now under the care of a physician?
Yes
No
If so, what is the condition being treated?
5.
The name and address of my physician is:
6.
Have you had any serious illness, operation, or been hospitalized in the last 5 years?
Yes
No
If so, what was the problem?
7.
Are you taking any medicine(s) including non-prescription medicine?
Yes
No
If so, what medicine(s) are you taking?
8.
Do you have or have you had any of the following diseases or problems?
a.
Damaged heart valves or artificial heart valves, including heart murmur or rheumatic heart disease?
Yes
No
b.
Cardiovascular disease (heart trouble, heart attack, angina, coronary
insufficiency, coronary occlusion, high blood pressure, arteriosclerosis,stroke)?
Yes
No
1.
Do you have chest pain upon exertion?
Yes
No
2.
Are you ever short of breath after mild exercise or when lying down?
Yes
No
3.
Do your ankles swell?
Yes
No
4.
Do you have inborn heart defects?
Yes
No
5.
Do you have a cardiac pacemaker?
Yes
No
c.
Allergy
Yes
No
d.
Sinus trouble
Yes
No
e.
Asthma or hay fever
Yes
No
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