Esph Patient History Form
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1
2
3MRN:
SURNAME:
OTHER NAMES:
PATIENT HISTORY FORM
DOB:
SEX:
AMO:
(Affix Addressograph Label Here - Hospital use only)
To be completed by Patient or Carer.
Please PRINT clearly. Your responses are valuable in planning your admission and caring for you during your stay.
ADMISSION DETAILS
Please specify the reason for your admission
NO
YES
COMMENTS OR FURTHER INFORMATION
Is this admission due to a past or present injury?
Cause of Injury:
Place:
Date
/
/
Have pathology/blood test/autologous blood been taken for
Pathologist:
this admission?
Results with:
Have X-rays been taken for this admission?
With patient
With doctor
What is your: Height .................cms
Weight .................Kgs
Blood Group (If Known) ...........................
MEDICATIONS
Have you recently taken blood thinning/arthritis medication
Name of Medication:
(Aspirin Based)?
Have you been instructed to cease this medication?
Date last taken
/
/
or still taking
Yes
Have you taken any steroids or cortisone tablets/injections in
Name of Medication
the last 6 months?
Date last taken
/
/
or still taking
Yes
Are you taking any other prescription or non-prescription
MEDICATION
FOR TREATMENT OF
FREQUENCY
DAILY DOSE
medication? List the medications you currently take (include
name of medication). Please bring all medications you are
currently taking with you on admission in the original packaging
GENERAL MEDICAL CONDITION
SPECIFY DETAILS
Type 1
Type 2
Unsure
Diabetes
Managed by
Diet
Tablets
Insulin
Cancer
Site:
Stroke
Date:
/
/
Residual problems
High blood pressure
Heart attack/chest pain/angina
Date:
/
/
Palpitations/irregular heart beat/heart murmur
Pacemaker
Make
Model
Last checked
/
/
Prosthetic heart valve
Type
Rheumatic Fever
Tendency to bleed/bloodclots/bruise easily
Arthritis
Asthma/bronchitis/pneumonia/hayfever
Liver disease/hepatitis (Specify type A, B, C)
Kidney/bladder problems
Hiatus hernia/gastrointestinal ulcers/bowel disorder
Thyroid problems
Epilepsy/fits/febrile convulsions
Depression/dementia/other mental illness
Migraines
Eye disease
Female patients could you be pregnant?
Number of weeks:
Impairment e.g. vision, hearing, mobility
History of pressure injuries
15
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Parent category: Medical