SANTA MONICACOLLEGE CONFIDENTIAL MEDICAL HISTORY

NAME / STUDENT ID# / SEX / BIRTHDATE / AGE
Last / First / Middle
LOCAL ADDRESS / PHONE
ARE YOU UNDER MEDICAL TREATMENT? / Yes / No / EXPLAIN:
DO YOU HAVE A PHYSICAL CONDITION WHICH REQUIRES SPECIAL ARRANGEMENTS? / Yes / No / APPROXIMATE DATE OF LAST VISIT TO PHYSICIAN
EXPLAIN:
YOUR DOCTOR’S NAME / DOCTOR’S ADDRESS / DOCTOR’S PHONE
LOCAL PERSON TO NOTIFY IN AN EMERGENCY
NAME / RELATIONSHIP / ADDRESS / PHONE
SIGNATURE / DATE
PERSONAL HISTORY / Have you ever had or do you now have any of the following? (If “yes,” explain in #18). ALL BOXES MUST BE ANSWERED.
“YES” ANSWERS MUST BEEXPLAINED. ANY CHANGE IN CHECKED BOXES, REQUIRES RE-EXAM BY YOUR HEALTH CARE PROVIDER.
Yes / No / (Check each item) / Yes / No / (Check each item)
1. HEAD / 6. GASTRONINTESTINAL / 9. MENTAL HEALTH (circle each item)
  1. Major dental problems
/
  1. Abdominal pain
/ Frequent nightmares, Trouble concentrating,
  1. Dizziness/Fainting
/
  1. Recent changes in appetite
/ Cry often, Feeling of depression,
  1. Encephalitis
/
  1. Recent changes of bowel habits
/ Tendency to worry, Memory loss, Mental
  1. Frequent headaches
/
  1. Recent constipation
/ health disorder, Considerable loneliness,
  1. Head injuries
/
  1. Frequent diarrhea
/ Have used narcotics, tobacco,
  1. Migraine
/
  1. Digestive disorder
/ amphetamines, Cocaine, Stimulants, LSD,
  1. Seizures/Convulsions
/
  1. Difficulty swallowing
/ or Other Hallucinogens more than once,
  1. Periods of unconsciousness
/
  1. Recurrent vomiting
/ Use of Alcohol, Marijuana, Tranquilizers,
2. EYES /
  1. Gastric or duodenal ulcers
/ Sleeping pills, Considerable nervousness,
  1. Allergies
/
  1. Hemorrhoids/Rectal fistula
/ Difficulty sleeping, Considered suicide,
  1. Eye disease or injury
/
  1. Other Ano-rectal disorder
/ Lose temper often
  1. Wear glasses
/
  1. Hepatitis
/ 10. BLOOD DISORDER (circle each item)
  1. Wear contact lenses
/
  1. Hernia
/ Anemia, Any unusual bleeding, Disease or Enlarge-
3. EARS/NOSE/THROAT /
  1. Intestinal worms
/ ment of glands/lymph nodes, Sickle Cell disease
  1. Frequent colds
/
  1. Jaundice
/ 11. CHRONIC DISEASE (circle each item)
  1. Severe tooth/gum infection
/
  1. Black bowel movements
/ Diabetes, Congenital Problems.
  1. Ear trouble
/
  1. Vomiting blood
/ Hypertension, Rheumatic fever, Other
  1. Hearing problem
/
  1. Intestinal inflammation
/ 12. ADDITIONAL MEDICAL HISTORY (circle each item)
  1. Frequent nose bleeds
/
  1. Gall bladder disease
/ Cancer, Operations, Recent gain or loss of weight
  1. Sinusitis
/ 7. GENITOURNINARY / Serious illness, Sexual problems, Skin disorder/
  1. Frequent sore throat
/
  1. Blood, albumin, sugar in urine (circle which)
/ Infections, STD’s, Unusual fatigue, Other
  1. Operation
/
  1. Kidney disease
/ 13. ALLERGIES (circle each item)
4. NECK /
  1. Kidney stones
/ Medications/Drugs, Bee stings, Foods, Hay
  1. Stiffness
/
  1. Bladder disease
/ Fever, Other ______
  1. Thyroid trouble
/
  1. Painful urination
/ 14. PAST ILLNESSES (circle each item)
  1. Enlarged glands
/
  1. Frequent urination
/ Measles, Mumps, Rubella, Chicken pox
5. CHEST/HEART/LUNGS/VASCULAR /
  1. Sexually transmitted disease
/ Other ______
  1. Breast disease or masses
/
  1. Genital disorders
/ 15. DRUGS RECENTLY TAKEN (circle each item)
  1. Chest pain/pressure/palpitation
/
  1. Prostatic/Testicular disorder
/ Cortisone, ACTH, Anticoagulants, Tranquilizers,
  1. Heart disease/murmur
/
  1. Other
/ Mood elevators, Anti-convulsants, Hypotensives
  1. High blood pressure
/ FEMALES / (high blood pressure medicines), Aspirin
  1. Rapid or irregular pulse
/
  1. Abnormal PAP smears

  1. Varicose veins
/
  1. Ovarian cysts
/ Have you ever received treatment for:
  1. Asthma
/
  1. Pelvic inflammatory disease
/ Asthma, Rheumatism, Rheumatic fever
  1. Chronic cough
/
  1. Vaginal discharge/itching
/ 16. IMMUNIZATION HISTORY (circle and date)
  1. Coccidioidomycosis (Valley Fever)
/
  1. Menstrual pain of irregularity
/ Tetanus Diphtheria Booster ______
  1. Emphysema
/
  1. Number of pregnancies
/ Polio: 1 ______
  1. Histoplasmosis
/
  1. Number of living children
/ 2 ______
  1. Lung disease
/
  1. Other
/ Measles/Mumps/Rubella:1 ______
  1. Night sweats
/ 8. MUSCULOSKELETAL/NEUROLOGICAL / 2 ______
  1. Pneumonia
/
  1. Arthritis or Rheumatism
/ Hepatitis A: 1 ______2 ______
  1. Tuberculosis
/
  1. Vertebrae disc problems
/ Hepatitis B:
  1. Pleurisy
/
  1. Swollen or painful joints
/ 1 ______2 ______3 ______
  1. Wheezing
/
  1. Bone infections
/ Varicella ______
  1. Shortness of breath
/
  1. Amputation
/ Flu ______
  1. Coughing up blood
/
  1. Speech defect
/ Other ______
  1. Stroke
/
  1. Paralysis, tremor, muscle

  1. Are you exposed to any fumes,
/
  1. Neuralgia, numbness

dusts, or solvents? /
  1. Back trouble

  1. Injuries

17. LIST SURGERY DATES:
18. EXPLAIN ALL “YES” ANSWERS IN ITEMS 1-8 AND ANY CIRCLED ITEMS FROM 9-15:

SANTA MONICACOLLEGE CONFIDENTIAL MEDICAL HISTORY

Yes / No
1. Has anyone in your family (grandmother, mother, father, brother, sister, aunt, uncle) died suddenly before the age of 50 years?
2. Have you ever passed out during exercise or stopped exercising because of dizziness?
3. Have you had asthma (wheezing), hay fever, or coughing spells after exercise?
4. Have you ever broken a bone, had to wear a cast, or had an injury to any joint?
5. Have you had a history of a concussion (getting knocked out)?
6. Have you ever suffered a heat-related illness (heat stroke)?
7. Have you had anything you want to discuss with the physician?
8. Have you had a chronic illness or see a physician regularly for any particular problem?
9. Are you taking any medicine? (Please name them below)
10. Do you have allergies to any medications? (Please name them below)
Explain any “yes” answers:

PHYSICAL EXAMINATION (to be performed by Physician)

Normal / Abnormal / Ht. / Wt. / TPR.
GENERAL: / BP / R:______/______L:______/______
Posture, gait, speech, appearance / Vision (uncorrected) R: 20/_____ L: 20/_____ Both: 20/_____
HEAD: / (corrected) R: 20/______L: 20/______Both: 20/______
Tenderness / Plus Sphere: ______Cover ______Color ______
EYES: / Pure tone Audiogram ______Pass ______Fail
Lids, Sclera, Conjuctiva, Muscles, Cornea, / 1st Step TB Mantoux:
Pupils, Fundi, Peripheral fields / Date done ______Date read ______Result ______
EARS: / Chest X-ray date ______Result ______
Pinna, Canal, Drum, Hearing / 2nd Step TB Mantoux:
NOSE: / Date done ______Date read ______Result ____
Septum, Obstruction, Mucosa / Chest X-ray date ______Result ______
MOUTH/THROAT: / ************************ATTACH ALL LAB RESULTS************************
Lips, Tonsils, Breath, Teeth, Tongue, Mucosa,
Pharynx / DETAILED DESCRIPTION OF ABNORMAL FINDINGS:
NECK:
Thyroid, Motion, Trachea, Veins
LYMPHATICS:
Cervical, Axillary, Inguinal, Supraclavicular
CHEST/LUNGS:
Symmetry, Percussion, Excursion, Sounds
CARDIOVASCULAR: / Student meets Physical Exam Requirements: No
PMI, Rate, Rhythm, Sounds, Murmurs, Neck / Student meets Physical Exam Requirements: Yes
Bruits, Upper Ext. Pulses, Lower Ext. Pulses, / Meets Requirements with Restrictions (explain):
Leg Veins, Edema, Abd. Bruits
BREASTS:
Masses, Discharge, Nipple/Areola, Scar
ABDOMEN:
Tenderness, Organs, Hernia, Masses, Sounds / Date Examined: ______
RECTAL: / Print MD Name: ______
Anus, Masses, Sphincter, Hemorrhoids
GU MALE: / MD Signature: ______
Address: ______
GYN: / Phone: ______
MUSCULOSKELETAL: / Please attach business card or professional stamp here
Back, Upper, Extremities, Lower Extremities
SKIN:
Birthmarks, Texture, Other lesions, Color
NEUROLOGIC:
Reflexes: Biceps, Triceps, Knee, Ankle,
Romberg, Babinski, Cranial N. Sensory,
Coordination, Tremor Vibratory
MENTAL STATUS:
Orientation, Affect, Judgement, Cognition/
Memory,Abstraction, Hallucination/Delusion

Updated 11/16/2009 DM