Medical History Form
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1Medical History
STUDY NAME
Visit Date:
Site Number:
___ ___ / ___ ___ ___ /
2
0
___ ___
______________________
d
d
m
m
m
y
y
y
y
Pt_ID:
______________________
Visit Type (circle one):
Screening
Baseline
Record all past and/or concomitant medical conditions or surgeries. Record only one condition or surgery per
line using the codes provided in the table. When recording a condition and surgery related to that condition
use one line for the condition and one line for the surgery.
01 Head, Eye, Ear, Nose, Throat
06 Musculoskeletal
11 Psychiatric
02 Respiratory
07 Neurological
12 Allergy
03 Cardiovascular
08 Endocrine/Metabolic
91 Other
04 Gastrointestinal
09 Blood/Lymphatic
05 Genitourinary
10 Dermatologic
Start Date
Current /
Code
Condition/Disease
dd/mmm/yyyy
Resolved
(one item per line)
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Medical History
Version 1.0
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Parent category: Medical