Medical History Form-Columbus Community Hospital Page 2
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2SOCIAL HISTORY:
A) Status: Single Married Widow Divorced
Child
B) Current Work Status: Employed Part-time Full-time Unemployed
Retired Self Employed Homemaker
Occupation: ____________________________ Date of Employment________________________
Employer: _________________________________________________________________________
Full Duty
Light Duty
Off work
Student, School Name: ___________________________
Disabled (Since___________)
Reason: _____________________________________________
C) Do you use tobacco products? No Yes If yes, how much and how long? _____________________
D) Do you consume alcohol? No Yes How much? ____________________________________
E) Do you exercise?
No Yes Type & Frequency _______________________________
F) Living Status: Alone With spouse With parents With roommate Assisted Living
Nursing Home With Other ________________________
Medications: NO MEDICATIONS
List any prescriptions, drugs, and/or non-prescription medications and dosage, including vitamins, nutritional
supplements, or anything taken orally. (Inform the nurse if you do not know how to spell the medication)
List Names of Medications:
1) _______________________________
5) _______________________________
2) _______________________________
6) _______________________________
3) _______________________________
7) ______________________________
4) _______________________________
8) _______________________________
NO KNOWN MEDICATION ALLERGIES
ALLERGIES:
Are you allergic to latex? Yes No
List Allergies:
Describe reaction:
1) ____________________________________
a) _________________________________
2) ____________________________________
a) _________________________________
3) ____________________________________
a) _________________________________
4) ____________________________________
a) _________________________________
FALL RISK ASSESMENT
1. Do you have a history of falling? Have you fallen in the past 6 months? Yes No
2. Have you been dizzy in the past 6 months?
Yes No
3. Use of ambulatory aids – ex. cane, crutches, walker, wheelchair, etc.
Yes No
4. Do you get dizzy when/after giving blood?
Yes No
REVIEW OF SYSTEMS: Are you currently having or have you ever had problems with:
Circle
Explain yes answer
Circle Explain yes answer
Eyes
NO YES _________________ Bladder/Bowel Problems NO YES _________________
Ears, Nose, Throat NO YES_________________ Balance Problems
NO YES _________________
Lungs, Breathing NO YES _________________ Numbness/Tingling
NO YES _________________
Digestion
NO YES _________________ Skin – Rashes/Open Sore NO YES _________________
Mood/Sleep Problems NO YES
_________________
Signature of staff entering Medical History Form __________________
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