Medical History FormGathering 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.

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Medical History Form: Downloads

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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 History

o  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 Use

What 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   No

o 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                           )

 

 

Tonometry

Right ______ 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.