Physical Examination And Medical History Form
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4Vinland National Center
Committed to full lives for people with disabilities.
PHYSICAL EXAMINATION AND MEDICAL HISTORY
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Participant name: _______________________________________________DOB:__________ Date of exam: __________________
***These items must be answered***
Current medical diagnoses: ________________________________________________________________________________
Mental health diagnoses:___________________________________________________________________________________
Current Medications: _____________________________________________________________________________________
Check box if no medications ____________________________________________________________________________
Past Medical History and Review of Systems; check if has or has had any of the following:
Requires 24-hour skilled nursing
Yes
No
Appears free of communicable disease
Yes
No
(if no, explain)_____________________________________________________
Mantoux (test is required for admission)
Date given: _____________________________________________
Date read/results:
___________________________________________
(must be within 30 days prior to admission)
Self preservation skills: In an emergency (fire alarm, gas leak, etc) is this person capable of taking appropriate action (getting
out of the building) for self preservation? Yes
No
Diet:
regular
mechanical
pureed
diabetic
Hepatitis, liver problem
Allergies: (medications, foods, insects)_______________________________________________
Vinland Standing Orders approved for PRN medications:
Yes
No
Note: please see enclosed sample copy of Vinland’s Standing Orders)
Exceptions: _____________________________________________________________________
History of MRSA? Yes No
Past medical history:
Review of systems
(current or recent):
Kidney disease
TBI or Head injury with LOC
Chronic cough or hemoptysis
Pancreatitis
Fractures
Night sweats
HIV or AIDS
Thyroid problems
Ear, nose, throat problems
Sexually transmitted disease
Asthma or difficulty
Swollen lymph nodes
Diabetes
breathing
Chest pain
Seizures
Emphysema/COPD/other
Shortness of breath
Cancer
chronic lung disease
Stomach problems
Bleeding disorder or sickle
TB or lived with anyone with
Constipation or diarrhea
cell
Hypertension
Hemorrhoids, black or
Suicide attempt
Heart disease
bloody stools
Mental health hospitalization
Stroke
Muscle, bone or joint
GERD or ulcers
problems
Hernia or rupture
Skin problems/Open wounds
Comments on positive responses from PMH and ROS above:
Past surgeries (year and procedure)
Hospitalizations (year and reason)
For office use only
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