Medical History Form
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1Occupational Medicine of Columbus
Patient:
Company:
Date of Service:
Patient ID:
Contact:
Birthdate: ___ / ___ / ______ Age: _____
Form: HISTORY
Page 1
Medical History
I certify that the information contained below is correct and complete to the best
of my knowledge and belief.
NOTICE: I understand that knowingly making a false
statement or omission in this record may be deemed sufficient cause for withdrawl
of my employment offer or dismissal after employment.
______________(Employee/ Applicant Initials)
EMPLOYEES JOB POSITION: _____________________________________________________
CHIEF COMPLAINT:_____________________________________________________________
PAST MEDICAL HISTORY:
1.
Have you had any medical problems or injuries previously?
___ YES
___ NO
If YES, list: __________________________________________________________
________________________________________________________________________
2.
Have you required hospitalization, had previous surgeries, had previous
broken bones, orthopedic injuries/ problems or had workers' compensation
injuries?
___ YES
___ NO
If YES, list: __________________________________________________________
________________________________________________________________________
________________________________________________________________________
3.
Are you under, or have you been under the care of a doctor at present for
any ongoing medical problems?
___ YES
___ N0
If YES, list care/treatment:____________________________________________
________________________________________________________________________
4.
Are you on any prescription medication? Over-the-counter?
___ YES
___ NO
If YES, list: ______________________________________
_________________________________________________________________________
5.
Are you ALLERGIC to any medication?___ YES
___ NO If YES, list: ________
_________________________________________________________________________
6.
Are you ______right or _______left hand dominant?
7.
Do you smoke? ___YES
___NO
#packs/day ___
#years smoked ___
8.
Do you use smokeless tobacco? ___YES
___NO
9.
Do you drink/ use alcohol?___YES
___NO
#beers/day ___ #drinks/day ___
10. Date of last tetanus shot _______________________________
11. Can you take a TB test YES/NO. Allergic or ever been exposed to TB? YES/NO
12. Have you received the Hepatitis B injection series?
___YES
___NO
13. Are you Pregnant?
___YES
___NO
14. Date of Last Menstrual Period?_______________________
15. Name of your personal physician:__________________________________________
PROBLEMS WITH OR HISTORY OF:
sugar or diabetes?
__YES __NO
thyroid problems?
__YES __NO
vision/eyes/cataracts/glaucoma?
__YES __NO
history of cancer?
__YES __NO
hearing/ears?
__YES __NO
kidney/bladder?
__YES __NO
lungs/asthma/bronchitis?
__YES __NO
arthritis/joint pain?__YES __NO
anemia/bleeding problems/
stomach/ulcers/
bruise easily/leg clots?
__YES __NO
vomiting?
__YES __NO
history of heart problems?
__YES __NO
high blood pressure? __YES __NO
nerve problems/anxiety/
neurological problems/
depression?
__YES __NO
numbness/weakness/tingling
seizures past or present?
__YES __NO
__YES __NO
lymph gland swelling/
drug and/or alcohol abuse?
frequent infections?
__YES __NO
__YES __NO
PHYSICIAN Reviewing ________________________DATE ____________________________
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