Confidential Health History

Work Form 5-1

Confidential Health History
Name: Date:
Birthdate: Age: Date of last physical examination:
Occupation:
Reason for visit today:
Medications List all medications you are currently taking / Allergies List all allergies
Symptoms Check {P} symptoms you currently have had in the past year.
General / Gastrointestinal / Eye, Ear, Nose, Throat / MEN only
£ Chills / £ Appetite poor / £ Bleeding gums / £ Breast lump
£ Depression / £ Bloating / £ Blurred vision / £ Erection difficulties
£ Dizziness / £ Bowel changes / £ Crossed eyes / £ Lump in testicles
£ Fainting / £ Constipation / £ Difficulty swallowing / £ Penis discharge
£ Fever / £ Diarrhea / £ Double vision / £ Sore on penis
£ Forgetfulness / £ Excessive hunger / £ Earache / £ Other
£ Headache / £ Excessive thirst / £ Ear discharge / WOMEN only
£ Loss of sleep / £ Gas / £ Hay fever / £ Abnormal Pap Smear
£ Loss of weight / £ Hemorrhoids / £ Hoarseness / £ Bleeding between periods
£ Nervousness / £ Indigestion / £ Loss of hearing / £ Breast lump
£ Numbness / £ Nausea / £ Nosebleeds / £ Extreme menstrual pain
£ Sweats / £ Rectal bleeding / £ Persistent cough / £ Hot flashes
Muscle/Joint/Bone
Pain, weakness, numbness in: / £ Stomach pain / £ Ringing in ears / £ Nipple discharge
£ Vomiting / £ Sinus problems / £ Painful intercourse
£ Arms / £ Hips / £ Vomiting blood / £ Vision – Flashes / £ Vaginal discharge
£ Other
Date of last
menstrual period
Date of last
Pap Smear
Have you had
a mammogram?
Are you pregnant?
Number of children
£ Back / £ Legs / Cardiovascular / £ Vision – Halos
£ Feet / £ Neck / £ Chest pain / Skin
£ Hands / £ Shoulders / £ High blood pressure / £ Bruise easily
Genito-Urinary / £ Irregular heart beat / £ Hives
£ Blood in urine / £ Low blood pressure / £ Itching
£ Frequent urination / £ Poor circulation / £ Change in moles
£ Lack of bladder control / £ Rapid heart beat / £ Rash
£ Painful urination / £ Swelling of ankles / £ Scars
£ Varicose veins / £ Sores that won’t heal
Medical History Check {P} the medical conditions you have or have had in the past.
£ AIDS / £ Chemical dependency / £ Herpes / £ Polio
£ Alcoholism / £ Chicken Pox / £ High Cholesterol / £ Prostate Problem
£ Anemia / £ Diabetes / £ HIV Positive / £ Psychiatric Care
£ Anorexia / £ Emphysema / £ Kidney Disease / £ Rheumatic Fever
£ Appendicitis / £ Epilepsy / £ Liver Disease / £ Scarlet Fever
£ Arthritis / £ Gall Bladder Disease / £ Measles / £ Stroke
£ Asthma / £ Glaucoma / £ Migraine Headaches / £ Suicide Attempt
£ Bleeding Disorders / £ Goiter / £ Miscarriage / £ Thyroid Problems
£ Breast Lump / £ Gonorrhea / £ Mononucleosis / £ Tonsilitis
£ Bronchitis / £ Gout / £ Multiple Sclerosis / £ Tuberculosis
£ Bulimia / £ Heart Disease / £ Mumps / £ Typhoid Fever
£ Cancer / £ Hepatitis / £ Pacemaker / £ Ulcers
£ Cataracts / £ Hernia / £ Pneumonia / £ Vaginal Infections
£ Venereal Disease
Confidential Health History

Work Form 5-1 (continued)

Hospitalizations
Year / Hospital / Reason for Hospitalization and Outcome
Have you ever had a blood transfusion? £ Yes £ No
If yes, please give approximate dates:
OCCUPATIONAL CONCERNS
Check {P} if your work exposes you
to the following: / HEALTH HABITS Check {P} which substances you use and indicate how much you use per day/week. / PREGNANCY HISTORY
Year of Birth / Sex of Birth / Complications if any
£ Stress / £ Caffeine
£ Hazardous Substances / £ Tobacco
£ Heavy Lifting / £ Drugs
£ Other / £ Alcohol
SERIOUS ILLNESS/INJURIES / DATE / OUTCOME
FAMILY HISTORY Fill in health information about your family.
Relation / Age / State of Health / Age of Death / Cause of Death / Check {P} if your blood relatives had any of the following
Disease / Relationship to you
Father / £ Arthritis, Gout
Mother / £ Asthma, Hay Fever
Brothers / £ Cancer
£ Chemical Dependency
£ Diabetes
£ Heart Disease, Strokes
Sisters / £ High Blood Pressure
£ Kidney Disease
£ Tuberculosis
£ Other
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Signature Date
Reviewed By Date

Continues