Employee Physical Examination And Medical History Page 3
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3CURRENT MEDICAL HISTORY
How often do you drink alcoholic beverages? __________________________________________________
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Do you smoke?
Yes
No
How many per day? ________________________________________
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Have you been hospitalized for any illness?
Yes
No
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Have you ever been advised to have any surgical operation which has never been done?
Yes
No
Give details: _________________________________________________________________________
DO YOU HAVE OR HAVE YOU HAD WITH THE PAST YEAR:
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Frequent or sever headaches
Yes
No Fainting Spells
Yes
No
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Dizziness on change of position
Yes
No Unconscious Spells
Yes
No
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Blurred vision
Yes
No Double vision
Yes
No
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Spots before eyes
Yes
No Infected eyes
Yes
No
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Pain behind eyes
Yes
No Any change in person
Yes
No
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Do you wear glasses
Yes
No When were eyes last checked
__________
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Earaches
Yes
No Discharge from ears
Yes
No
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Ringing in ears
Yes
No Decrease in hearing
Yes
No
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Recurrent nose bleeds
Yes
No Recurrent head cold
Yes
No
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Sinus trouble
Yes
No Hay fever
Yes
No
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Persistent hoarseness
Yes
No Difficulty in swallowing
Yes
No
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Enlarged glands
Yes
No Recurrent sore throat
Yes
No
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Chest pain
Yes
No Agina Pectoris (chest pain)
Yes
No
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Coughed up blood
Yes
No Pain in arm(s)
Yes
No
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Chronic or frequent cough
Yes
No Palpitations or heart flutters
Yes
No
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Wake at night short of breath
Yes
No Leg cramps on walking or at night
Yes
No
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Short of breath on:
Recurrent stomach pain
Yes
No
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walking several blocks
Yes
No Backaches
Yes
No
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laying down
Yes
No Swelling of joints
Yes
No
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walking one flight of stairs
Yes
No Tingling/weakness in hands/feet
Yes
No
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Purple lips or fingers
Yes
No Loss of/change in hands/feet
Yes
No
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High Blood Pressure
Yes
No Enlarged veins in legs
Yes
No
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Recurrent back pains
Yes
No Joint pains
Yes
No
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Redness or heat in any joint
Yes
No Muscle spasms
Yes
No
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Any menstrual problems
Yes
No
X-RAYS: Have you ever had x-rays of:
IMMUNIZATIONS: Have you had:
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Gall bladder
Yes
No
Hepatitis B
Yes
No Date ____________
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Back
Yes
No
MMR
Yes
No Date ____________
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Stomach or colon
Yes
No
Tetanus
Yes
No Date ____________
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Extremities (arms or legs)
Yes
No
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EKG
Yes
No
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Electrocardiogram
Yes
No
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Have you ever taken insulin or tablets for diabetes?
Yes
No
I certify that the information given is accurate to the best of my knowledge.
Signature ____________________________________________________
Date ___________________
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