Adult Pre-Clinical History Page 2
ADVERTISEMENT
1
2
3
4MEDICAL HISTORY
Name of personal physician: ________________________________________________________________________________
Address: ________________________________________________________ Phone number: __________________________
Approximate date of last visit:____________________ Current health condition:
Excellent
Good
Fair
Poor
Have you had any serious health problems in the last five years?
yes
no If yes, please explain: ________________
__________________________________________________________________________________________________________
(For women) Are your currently pregnant?
yes
no If yes, how many months? ________________________________
Please list prescription medications: __________________________________________________________________________
__________________________________________________________________________________________________________
Please list vitamin/herbal supplements? ______________________________________________________________________
__________________________________________________________________________________________________________
Do you know your blood pressure?
yes
no (If yes, what is it?) ______________________________________________
Please check if you’re allergic to any of the following:
Local anesthetics
Sulfa drugs
Codeine/other narcotics
Penicillin/other antibiotics
Aspirin
Latex sensitivity
Barbiturates, sedatives, sleeping pills
Shellfish, iodine or red wine
Other__________________________
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Drug Addiction
Hepatitis B or C
Renal Dialysis
Alzheimer's Disease
Easily Winded
Herpes
Rheumatic Fever
Anaphylaxis
Emphysema
High Blood Pressure
Rheumatism
Arthritis/Gout
Epilepsy or Seizures
High Cholesterol
Scarlet Fever
Artificial Heart Valve
Excessive Bleeding
Hives or Rash
Shingles
Artificial Joint
Excessive Thirst
Hypoglycemia
Sickle Cell Disease
Asthma
Fainting Spells/Dizziness
Irregular Heartbeat
Sinus Trouble
Blood Disease
Frequent Cough
Kidney Problems
Spina Bifida
Blood Transfusion
Frequent Diarrhea
Leukemia
Stomach/Intestinal Disease
Breathing Problem
Frequent Headaches
Liver Disease
Stroke
Bruise Easily
Genital Herpes
Low Blood Pressure
Swelling of Limbs
Cancer
Glaucoma
Lung Disease
Thyroid Disease
Chemotherapy
Hay Fever
Mitral Valve Prolapse
Tonsillitis
Chest Pains
Heart Attack/Failure
Osteoporosis
Tuberculosis
Cold Sores/Fever Blisters
Heart Murmur
Pain in Jaw Joints
Tumors or Growths
Congenital Heart Disorder
Heart Pace Maker
Parathyroid Disease
Ulcers
Convulsions
Heart Trouble/Disease
Psychiatric Care
Venereal Disease
Cortisone Medicine
Hemophilia
Radiation Treatments
Yellow Jaundice
Diabetes
Hepatitis A
Recent Weight Loss
Have you ever had any serious illness not listed above? If yes, please explain:____________________________________________
__________________________________________________________________________________________________________
When a health care worker is exposed to my blood or body fluids through a needle stick, cut or splash to the eye or mouth,
I agree to have my blood tested for blood-borne diseases to include Hepatitis B and C Virus and Human Immunodeficiency
Virus (AIDS). Initial: __________
The information I have given is true and accurate to the best of my knowledge.
Signature ____________________________________________________________ Date ________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical