MEDICAL HISTORY RECORD
All information
I
Case No.
Medicare
is treated as confidential
I
No.
Last Name
First
Address
City
Medicaid
unless you grant permission
No.
Middle
Daytime
By Doctor
Phone
May I contact either of these
Doctors for your past health records?
Yes
No
IF LIVING
Family History
D
D
I
Zip
Phone
all information.
I
Birth date
D
Male
D
Occupation
Marital Status
I Last
Family or Referring
I
Doctor
Physical
Examination
Date
Phone No.
What are your present medical symptoms?
Any blood relatives
who have or have had any of the listed conditions
V Yes No
Death Cause
V Yes No
Relationship
Father
Asthma
Hay Fever
Mother
Arthritis
Insanity
Brothers (Circle
Sisters
Sex)
Allergies
Kidney Disease
1. M F
Anemia
Leukemia
2. M
F
Alcoholism
Migraine
3. M
F
Bleeding Tend.
Nervous Break'n
4. M
F
Cancer
Obesity
Colitis
Rheumatism
5. M F
D
D
Husband
Wife
Female
Home Phone
Relationship
IF DECEASED
r.-_l--:::-H_E-;-A-;::L,..,T,...H-;::---i
Death
Age
Good Fair Poor
Age
I
Date
Daytime phone
State
Person to notify in emergency
to release it. Please print and complete
Today's
Congenital
Sons
(circle
Daughters sex)
Rheumatic
Heart
Diabetes
Stroke
Relationship
Fever
1. M
F
Epilepsy
Suicide
2. M
F
Goiter
Stomach
3. M
F
High BI. Press.
Tuberculosis
4. M
F
Heart Disease
Ulcers
5. M F
6. M
F
Do You
Smoke
HABITS
No
Daily Consumption:
_______
Pkqs,
.0 0
_______
Cups
.0 0
_________
oz.
.0 0
v Yes
Drink Coffee
Drink Alcohol
Drink Beer.
0
________
oz.
v
.0
.0
Aspirin, Bufferin, Anacin
0
Barbiturates....
....0
Antacids..........
Antibiotics
.
v
Blood Thinning
Cort~one
Pills
Cough Medicine
Digitalis
Fall Asleep Easily ..0
0
Birth Control Pills
'O
Dilantin
Hormones
Awaken Early
0
Blood Pressure Pills
0
Insulin, Diabetic Pills
O
0
MEDICATIONS
v If Taken
Operations
you have had:
Drugs you
are allergic
to:
Diseases
requiring
Year
you have had
hospitalization
Describe any serious injuries
accidents you have had
v
WOMEN only:
Are you still having regular monthly menstrual periods?....
Have you ever had bleeding between your periods?
Do you have very heavy bleeding with your periods?
Do you feel bloated and irritable before your period?
Are you now on or have you ever taken the birth control pill?
Have you ever had a miscarriage?
Have you ever had a discharge from the nipple of your breast?
Do you regularly have the cancer test of the cervix?
How many children born alive....
__
How many stillbirths ................................•••..•....••....
How many premature births ............................••••...
Date of last menstrual period
......••••... __
How many miscarriages
.
How many cesarean operations...
..
.
Any complications of pregnancy?
(explain)
Item 4702
Year
..
..
..
--------------------
Yes
0
0
0
.. .0
.0
0
0
.0
No
0
0
0
0
0
0
0
0
v
0
Iron or Poor Blood Med
0
O
0
O
Laxatives
Phenobarbital...
Shots......
0
Thyroid Med.
Tranquilizers
0
Sleeping Pills.
.0
..
..
..
..
0
0
0
0
v
Vitamins
Water Pills.
Weight Reducing
Other (Iist)
0
.0
0
..
Pills
_
0
.0
Serious illness not
requiring hospitalization
Year
or
When?
_
When?
_
When?
When?
When?
Date of last test
_
_
_
_
MEN only: Have you ever had:
Loss of sexual activity? For how lonq?
Treatment for genitals (private parts)?...
Discharge from penis?
Hernia (rupture)?
Prostate trouble?
v
Yes
0
No
0
......0
....0
0
.. .0
0
0
0
0
_
MEN and WOMEN:
Do you frequently
have severe headaches
V Yes
No
...0
o
.....
Have you recently
(If yes, answer the following):
Do they cause visual trouble?
Do they awaken you at night? ..
Do they hurt most in the back of the head and neck?
0
Awakens you at night? ..
0
0
Is relieved by antacid medications?
0
0
Is relieved with milk or eating?
...0
0
Occurs while eating or immediately
0
0
Is relieved by a bowel movement?
.. ..0
0
Causes loss of appetite?
V Yes
No
..
Does aspirin relieve them?
V Yes
No
Do you frequently
Have you ever fainted?
.0
0
Have you ever had a convulsion?
.0
0
Bleeding gums?
Spells of dizziness?
0
0
Double vision?
0
0
Trouble swallowing?
Spells of weakness
of arm or leg? .0
0
Pains in ear? .
.0
0
Hoarseness?
0
0
Nosebleeds?
.0
0
Ringing in ears?
Have you ever had shortness
breath?
of
..
v Yes
No
Have you had pain or tightness
in the chest which begins:
..
.0
0
When exerting yourself?
..
0
0
When walking against a wind? ..
Which awakens you at night? .....
....0
0
Do you have a chronic cough? .
...0
..
Climbing a flight of stairs?....
Which causes you to cough?
by wheezing?
Have you ever coughed
blood? ..
..
Do you cough up much sputum?
v Yes
Have you had?
Burning when urinating?
.0
No
..
.
v Yes
have:
..
No
0
A sore tongue?
.0
0
Nausea and vomiting?
0
0
0
Radiates down the arm? .
.......
0
0
Disappears
When walking up a hill? .
......0
0
Occurs only at rest?
0
After a heavy meal? ......................
......0
0
When walking fast?
0
0
When upset or excited? .
...... 0
0
When walking in cold weather?
..0
0
Palpitations.
...... .0
0
If you have chest pain or tightness
.0
0
Do you sleep on more than one pillow? ................... .0
0
....0
0
When or since when?
,Have you recently
had:
Pains in calves of legs when
v Yes
No
0
0
walking?
.0
0
0
0
Cramps in legs at night?
.0
0
0
0
Pain in the big toe? ..
0
0
Trouble starting to urinate?
.0
0
Varicose veins?
0
0
Trouble holding the urine?
0
0
Phlebitis or inflamed leg veins?
.0
0
0
0
Swelling in the ankles
.0
0
0
0
To get up frequently
at night?
Passed a kidney stone? ..
..
If you have had a change in bowel habit
recently answer the following:
When or since when?
v Yes
No
Crampy pain in abdomen?
0
0
diarrhea and constipation?
..0
0
Pain during or after bowel movement?
.0
Alternating
Mucous in the stool?...
......................0
0
0
Blood in the stool?
.0
0
Ribbon like stools?
0
0
Black stools?
0
0
Require use of strong laxatives or enemas?
.0
0
o
0
.
No
0
0
o
o
v Yes
No
..
..
0
0
...0
0
.
please explain
When or since when?
Describe briefly your present medical
symptoms
and anything else we should
know about your health.
o
v Yes
if you rest?
Loss of control of bladder?
.
......
.0
..............
0 o
.0
No
0
o
.....................
.0 o
.
v Yes
..................
o
................................
.0 o
.
after? ...............•...........
.............•........
..
.......................
No
0
.............................
0 o
............ .0
............
..
..............................
0 o
.
Blood in the urine?
Dark colored urine? .
V Yes
.................
...........................
.0
..0
..
Do they feel like a tight hat band? .
Accompanied
which:
.
Is brought on by eating fried foods, gassy foods?
Do they occur on one side of the head?
DOing your usual work?
had pain in the stomach
Occurs 1-2 hours after a meal?
.
0
0
0
0
0
0