Medical History Form
Gathering a complete and accurate medical history evaluation form is extremely important as genetic medicine explains more diseases. The Medical History Form has been developed to aid both the physician/health care provider and the patient in documenting family history.
Medical History Form: Downloads
Page Contents
Medical History Form: Example
| Name, address, and phone number (including fax) of physician/ health center performing examination:
| New Applicants ONLY: Your Current Occupation:
Your Current Employer:
Time in Current Position (in years/months): | ||
| Examinee’s Name: | Position/Job Title: | SS# | |
|
Address: | Work Location: | Region: | |
| Home Phone: | Work Phone: | ||
| Date of Scheduled Exam: | Date of Birth: | Gender: Male o Female o | |
| EXAMINING PHYSICIAN | |||
| BASELINE CORE EXAM
Required Services: (Check those services completed) o Authorization for Disclosure Form o General Medical History o General Physical Examination o Chemistry Panel (including Glucose, Bilirubin (total), Cholesterol, HDL-C, LDL-C, Triglycerides, GGTP, LDH, SGOT, SGPT), Complete Blood Count, and Urinalysis o Audiometry (including noise exposure history) o Electrocardiogram o Spirometry o Vision Screening (Corrected and Uncorrected Near and Far; Color; Peripheral; Depth Perception) o Plus other Function or Clearance-required services (see the following page)
| PERIODIC CORE EXAM
Required Services: (Check those services completed) o Authorization for Disclosure Form o General Medical History o General Physical Examination o Chemistry Panel (including Glucose, Bilirubin (total), Cholesterol, HDL-C, LDL-C, Triglycerides, GGTP, LDH, SGOT, SGPT), Complete Blood Count, and Urinalysis o Plus other Function or Clearance-required services (see the following page)
| ||
| PAST MEDICAL HISTORY(Please complete this page if this is your first time using this form, or if you are unsure if you have completed it before.) | ||
| A. Have you ever been treated for a mental or emotional condition? (If Yes, specify when, where, and give details.) o Yes o No
B. Have you had or have you been advised to have any operation? (If Yes, specify when, and give details.) o Yes o No
C. Have you ever been a patient in any type of hospital after infancy? (If Yes, specify when, where, and give details.) o Yes o No
D. Have you ever been treated with an organ transplant, prosthetic device (e.g., artificial hip), or an implanted pump (e.g., for insulin) or electrical device (e.g., cardiac defibrillator)? (If Yes, please describe fully, and provide copies of pertinent medical records.) o Yes o No
E. Have you ever had any other serious illness/injury? (If yes, specify when, where, and give details.) o Yes o No
F. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past year for other than minor illness? (If Yes, specify when, where, and give details.) o Yes o No
G. Have you ever been rejected for military service or discharged from military service because of physical, mental, or other health reasons? (If Yes, give date and reason for rejection.) o Yes o No
H. Have you ever received, is there pending, or have you applied for a pension or compensation for a disability? (If Yes, specify what kind, granted by whom, what amount, when, and why.) o Yes o No
| Every item checked “Yes” must be explained below or on the back of this form.
| |
| WELLNESS/HEALTH PROFILE
Smoking Historyo Current Smoker Number of cigarettes per day Number of cigars per day Number of pipe bowls per day Total years you have smoked
o Former Smoker Years since quitting _______ Number of cigarettes per day Number of cigars per day Number of pipe bowls per day Total years you smoked Alcohol/Drug UseWhat is your average alcohol consumption (number) in a week?
Drinks
(1 drink = 12 0z. beer, 1 glass wine or 1.5 oz liquor)
When do you drink alcohol? o Weekdays o Weekends o Both o Don’t drink | RESPIRATOR CLEARANCE QUESTIONS
Have you ever used a respirator? Yes o Noo Will you use one in the coming year? Yes o Noo (If no, please skip the rest of this section.)
What hazards may be present during your use of a respirator? o High altitude o Temperature extremes o Confined spaces
Have you ever had, or do you now have any of the following? Yes Noo o Persistent cough or shortness of breath o o Unexplained general weakness or fatigue o o Asbestosis or silicosis o o Lung cancer o o Broken ribs or chest injury o o Chest pain on deep inspiration o o Sensation of smothering when using a respirator o o Heat exhaustion or heat stroke o o Trouble smelling odors o o Difficulty squatting o o Difficulty climbing stairs or ladder carrying 25# weight o o Other conditions that might interfere with respirator use or result in limited work activity (Discuss all “Yes” responses with the examining physician.) | Fully explain all medical problems identified in Respirator Clearance Questions section.
MEDICATIONS List all medications (prescription and over-the-counter) you are currently taking.
|
| Describe Your Physical Activity or Exercise Program(check one)
Intensity: Low Moderate High Duration, in Minutes per Session
Describe activity Frequency Days per week
| ||
| MEDICAL HISTORY |
| VASCULAR Yes NoDo you have any vascular (blood vessel) disease? o o Enlarged superficial veins, phlebitis, or blood clots? o o Anemia? o o Hardening of the arteries? o o High Blood Pressure? o o Heart failure? o o Stoke or Transient Ischemic Attack (TIA)? o o Aneurysms (Dilated arteries)? o o Poor circulation or swelling of the hands or feet? o o White fingers with cold or vibration? o o |
| DIAGNOSTIC AND PHYSICAL FINDINGS |
| Cardio/Pulmonary Normal Abnormal o o Lungs/Chest o o Heart (thrill, murmur) o o Vascular (varicosities, stasis, insufficiency) o o Electrocardiogram – Attach with interpretation, if done o o Stress EKG – Bruce Protocol, attach with interpretation, if exam requires
_______________________________________________________________
Pulmonary Function Testing: (Attach Copy)
Calibration Date (Should be same day as test) Machine Brand |
| CHEST X-RAY Last PA Chest X-ray: Date Result: o Normal o Abnormal
Comments:
TB Mantoux (PPD) Date:
mm Induration:
VITAL SIGNS
Height (inches) Weight (pounds)
Blood Pressure / mm/hg
Pulse /MIN (Conduct vital sign measurements while sitting; if elevated, repeat in 15 min.) |
| RESPIRATORY Yes NoDo you have any respiratory (lung/airway) disease? o o Asthma (including exercise induced asthma)? o o (Do you use an inhaler?) o o Bronchitis? o o Emphysema? o o Acute or chronic lung infections? o o Persistent or recurring coughing or wheezing? o o Wind pipe or lung surgery? o o Collapsed lung? o o Scoliosis (curved spine) with breathing limitations? o o History of Tuberculosis? o o Previous positive TB skin test? o o Date: |
| ActualFVC
|
| ActualFEV1 |
| Actual FEV1/FVC |
| ActualFEF 25-75 |
| Respirations /MIN Temp(if indicated) IMMUNIZATIONS
Last Tetanus (Td) Shot (Date): Given today? o Yes o No
Has client received Hepatitis B Vaccine? o Yes o No o Declined o Not Applicable Hep B series complete? o Yes o No When?
Date Immunization #1:______ #2:______ #3:______
Has client received Hepatitis A Vaccine? o Yes o No o Declined o Not Applicable Hep A series complete? o Yes o No
Date Immunization #1:______ #2:______ |
| Comments/Findings on Vascular / Respiratory / Heart sections |
| HEART Yes NoDo you have any heart disease? o o Heart pain (Angina)? o o Heart rhythm disturbance or palpitations (irregular beat)? o o History of Heart Attack? o o Organic heart disease (including prosthetic heart valves, mitral o o stenosis, heart block, heart murmur, mitral valve prolapse, pacemakers, Wolf Parkinson White (WPW) Syndrome, etc.)? Heart surgery? o o Sudden loss of consciousness? o o Other (specify)? o o |
|
Cardiac Risk Profile (record here, or attach report)
Chol HDL LDL Trig Gluc
Attach copy of complete blood count (CBC) report, including differential |
| CORONARY RISK FACTORSYes No Blood Pressure > 145/90 o o Fasting Glucose > 120 mg/dl o o Total Cholesterol > 200 mg/dl o o Family history of CVD in members < 55 o o Obesity o o No regular exercise program o o Currently smoking or > pack/yr history o o
|
| MEDICAL HISTORY |
| ENDOCRINE Yes NoDo you have any endocrine (hormone) disease? o o Diabetes (insulin requiring; units per day ______)? o o (Year of diagnosis____________) Diabetes (non-insulin requiring)? o o (Year of diagnosis____________) Childhood Onset Diabetes? o o Thyroid Disease? o o Obesity? o o Unexplained weight loss or gain? o o |
| MENTAL HEALTH Yes NoDo you have any psychiatric or mental health problems? o o History of psychosis? o o Psychiatric/psychological consultation? o o Difficulty dealing with stress? o o Panic attacks, hyperventilation, or anxiety or phobia disorder? o o Periods of uncontrollable rage? o o Claustrophobia? o o Diagnosed depression, personality disorder, or neuroses? o o |
| MUSCULOSKELETAL Yes NoDo you have any muscle or bone disease? o o Moderate to severe joint paint, arthritis, tendonitis? o o Amputations? o o Loss of use of arm, leg, fingers, or toes? o o Loss of sensation? o o Loss of strength in hands, arms, legs or feet? o o Loss of coordination? o o Back injury? o o Chronic back pain? o o (back pain associated with neurological deficit or leg pain) Are you RIGHT o or LEFT o handed? (check one) |
| DIAGNOSTIC AND PHYSICAL FINDINGS |
| OBSTETRIC Yes No NA*Are you currently pregnant? o o o
*Male; question not applicable
|
| Comments/Findings(Attach copy of blood chemistry panel report.) |
| DERMATOLOGY/ALLERGYYes No Do you have any skin or allergy diseases? o o Sun sensitivity? o o Allergic dermatitis to rubber or latex? o o History of chronic dermatitis? o o Active skin disease or infections? o o Moles that have changed in size or color? o o Allergies, including hay fever? (If so, to what?) o o |
| Comments/Findings |
Musculoskeletal
Normal Abnormal o o Upper extremities (strength) o o Upper extremities (range of motion) o o Lower extremities (strength) o o Lower extremities (range of motion) o o Feet o o Hands o o Spine, other musculoskeletal o o Flexibility of neck, back, spine, hips, knees
Comments/Findings
|
| Please assess the following, if box is checked: o Medically cleared to perform the following: Yes No o o Vigorous aerobic exercise program 3 hr/wk o o Push ups o o Pull ups o o Sit ups o o One and one half mile (1 1/2) timed run o o 3-mile timed walk o o Squat/rise w/o holding on; hold squat 45 sec. o o Kneel on one knee, arms extended for 7 sec. o o Assume a 1 then 2 knee kneeling position within 2 seconds, rise without assistance, repeat
Comments/Findings
|
| MEDICAL HISTORY |
| NEUROLOGICAL Yes NoDo you have any neurological disease? o o Tremors, shakiness? o o Seizures (recent or previous)? o o Spinal Cord Injury? o o Numbness or tingling? o o Head/spine surgery? o o History of head trauma with persistent deficits? o o Chronic recurring headaches (migraine)? o o Brain tumor? o o Loss of memory? o o Insomnia (difficulty sleeping)? o o |
| GASTROINTESTINAL Yes NoDo you have any stomach or intestinal disease? o o Hernias? o o Colostomy? o o Persistent stomach/abdominal pain or heartburn? o o Active ulcer disease? o o Hepatitis or other liver disease? o o Irritable bowel syndrome? o o Rectal bleeding? o o Vomiting blood? o o |
| GENITOURINARY Yes NoDo you have any disease of the urinary system or genitals? o o Blood in urine? o o Kidney Stones? o o Difficult or painful urination? o o Infertility (difficulty having children)? o o |
| DIAGNOSTIC AND PHYSICAL FINDINGS |
Neurological
Normal Abnormal o o Cranial Nerves (I – XII) o o Cerebellum o o Motor/Sensory (include vibratory and proprioception) o o Deep Tendon reflexes o o Mental Status Exam
|
| Comments/Findings |
Gastrointestinal
Normal Abnormal o o Auscultation o o Palpation o o Organo-megaly o o Tenderness o o Inguinal hernia
Attach blood chemistry panel report
|
| Comments/Findings |
Genitourinary
Normal Abnormal o o Urogenital exam
(Attach urinalysis report, if done.)
|
| Comments/Findings
|
| MEDICAL HISTORY | ||||||||
| VISION Yes NoDo you have any vision problems or eye disease? o o Frequent headaches? o o Blurred vision? o o Loss of vision in either eye? o o Eye irritation when using a respirator or goggles? o o Difficulty reading? o o Eye disease, glaucoma? o o Eyeglasses? o o Contact lenses? o o Cataracts? o o Color blindness? o o Have you had any type of eye surgery (e.g., radial keratotomy, PRK [laser], o o cataract, etc.)? If “YES”, please provide specific type and date of surgery:
HEARING Yes No Do you have any hearing problems or ear disease? o o Exposure to loud, constant noise or music in the last 14 hours? o o Exposure to loud, impact noise in past 14 hours? o o Ringing in the ears? o o Difficulty hearing? o o Ear infections or cold in the last 2 weeks? o o Dizziness or balance problems? o o Eardrum perforation? o o Do you use a hearing aide? o o Are you in a Hearing Conservation Program? o o | ||||||||
| DIAGNOSTIC AND PHYSICAL FINDINGS | ||||||||
| Head and Neck Normal Abnormal o o Head, Face, Neck (thyroid), Scalp o o Nose/Sinuses/Eustachian tube o o Mouth/Throat o o Pupils equal/reactive o o Ocular Motility o o Ophthalmoscopic Findings o o Speech
Comments/Findings
| ||||||||
| Eyes / Vision Color Vision Normal Abnormal Number Correct: o o _____ of _____ tested Can see Red/Green/Yellow? o Yes o No
Type of test o Ishihara plate o Function test (Yarn, wire, etc.) o Other (specify )
TonometryRight ______ mm/Hg Left ______ mm/Hg
Visual Acuity Corrected vision (Snellen Units)
Both Near 20/ Right Near 20/ Left Near 20/
Both Far 20/ Right Far 20/ Left Far 20/
Uncorrected vision (Snellen Units)
Both Near 20/ Right Near 20/ Left Near 20/
Both Far 20/ Right Far 20/ Left Far 20/
Peripheral Vision Right Nasal_____degrees Temporal_____degrees
Left Nasal_____degrees Temporal_____degrees
Depth Perception (Type of test:________________________) o Normal o Abnormal Number Correct:
_____ of _____ tested
Interpretation: _____ Seconds of Arc
| ||||||||
| Ears Right Normal Abnormal o o Canal/External ear o o Tympanic Membrane
Left o o Canal/External ear o o Tympanic Membrane
Comments/Findings:
| ||||||||
| Do you use protective hearing equipment? o oIf yes, type(s): o foam o pre-mold/plugs o ear muffs Have you had prior Military Service? o o Have you had prior ear surgery? o o Have you had recurrent ear infections? o o
| ||||||||
| Frequency | ||||||||
| 500Hz1000Hz2000Hz3000Hz4000Hz6000Hz8000Hz | ||||||||
| Right ear
| ||||||||
| Left ear
| ||||||||
Impressions:
1)
2)
3)
4)
5)
Plan:
1)
2)
3)
4)
5)
| PROFESSIONAL STAFF Please check all the topics you discussed during the diagnostic work-up or physical examination |
| o Diet oLow-calorie oLow-fat oLow-salt o Cholesterol
o Hypertension
o Exercise
o Obesity
o Smoking Cessation
o Avoid Sun Exposure/Sun Screen
o Alcohol Use
o Cancer Screening
o Immunizations
o Hearing Protection
o Vision Referral
o Other Personal Protective Equipment
o Job Stressors
o Referral(s)
Others
|
| EXAMINING PHYSICIAN: WORKPLACE EXPOSURE MONITORING |
| Is workplace monitoring data or other exposure data for this employee or this position available for your review? ¨ Yes ¨ No
If yes, what type of data is available? ¨ Acute Exposure Data ¨ Periodic Exposure Data ¨ Ongoing Workplace Monitoring Data ¨ Individual Dosimetry Data ¨ Material Safety Data Sheets
How was data made available? ¨ Electronic Database ¨ Hard Copy Report ¨ Employee Self-Report
If exposure data was available, please explain what changes, if any, were made in the examination due to this data:
Based upon your knowledge of the physical demands of the position and/or the potential exposure to occupational hazards, please answer the following:
Does the employee need to be in a medical surveillance program? ¨ Yes ¨ No ¨ Cannot determine based on information available ¨ Other |
| EXAMINING PHYSICIAN Summary of Abnormal Findings with Plan of Action/Referral |
SIGNATURES DATE
Nurse_________________________________________________________________________________________________
Examining Physician____________________________________________________________________________________
Examinee (person having the examination):_______________________________________________________________________________________
Medical History Form: Uses
Medical History Form helps address family history collection, interpretation, and application in busy primary care practices. The tool helps to improve health outcomes by providing clinical decision support and educational resources for risk assessment based on family and past medical history.
Medical History Form may be useful for a physician/health care provider to gather information from a couple either prior to pregnancy or during a pregnancy. This form may be printed out and filled in by the patient prior to a doctor’s appointment. It may also be presented to the patient while the patient is in the waiting room, thus saving time on gathering history during a consultation.
The Adult Family History Form is more likely to be useful when a patient is being seen in clinic to rule out a condition that may have developed later in life, which may or may not have been inherited.
The Medical History Form also provides a physician/health care provider with useful information about the utility of a family history in identifying disease risk and developing a personalized prevention program.