Personal And Family Medical History (Page 2 of 2) in pdf

Personal And Family Medical History Page 2

PERSONAL AND FAMILY MEDICAL HISTORY

Name

Date of Birth

Student ID#:

(office use only)

Family/Last

First

Middle

Drug Allergies/Medicine Sensitivity

Do you smoke?

□ None

□ Yes

□ No

□ Penicillin, Ampicillin

□ Latex Allergy

□ Sulfa Drugs (please specify) _________________________________________

□ Others (please specify) _________________________________________________________________

□ Food Allergies ________________________________________________________________________

Current Medications – taken on a regular basis (i.e. insulin, birth control pills, seizure, or heart medicine)

□ None

Date Started

Name of Medication

Dosage

Current (or past) Medical Problems (i.e. seizures, diabetes, thyroid problems, asthma, heart problems,

allergies, etc.)

□ None

Date Started

Name of Medical Problem

Hospitalizations and Surgeries (Please list ALL)

□ None

Date

Family History of Illnesses – Please list if there is a family (e.g. grandparents, siblings) history of illness

such as diabetes, high blood pressure, sudden/unexplained deaths, etc.:

_______________________________________________________________________________________

Revised 04/18/13

C-11

Personal And Family Medical History Page 2