Nursing/Teaching ExamMedical History form --- to be completed by student

Age: _____ Sex: M F Allergies to medications: ______

Current medications: ______

Current medical illness being treated: ______

Do you have any concerns about your ability to function in clinical nursing/teaching? Y N

Past hospitalizations (year/reason) ______

Past treatment for illnesses (diabetes, thyroid, heart murmur, depression, eating disorder, other______

Social History

Do you smoke cigarettes? Y N Packs per day: Use other tobacco products? Y N

Do you drink alcohol? Y N Drinks/week average: Do you use recreational drugs? Y N

Do you ever drink and drive or ride with people who drink and drive? Y N

Do you wear seat belts? Y N Do you exercise? Y N Number sessions/week:

Family History: Have immediate relatives (parents, brothers, sisters) had?

Y / N / Relationship / Y / N / Relationship / Type
High Blood Pressure / Cancer
Stroke / Thyroid disease
Heart Attack age <50 / Blood clotting disorder
Diabetes / Psychiatric illness

REVIEW OF SYSTEMS: Have you had during the last year: (CIRCLE any that apply)

General: unexplained weight changes, unusual fatigue, fever, chills, sweats at night

Skin: changes in existing moles, new moles, poorly healing wounds, rashes

Eyes/Ears: blurred vision, double vision, loss of hearing

Cardiac: chest pain, racing or irregular heart beat

Lungs: cough, wheezing, shortness of breath with activity

Gastrointestinal: diarrhea, constipation, change in bowel habits, blood in stool,dark black stools, abdominal pain

Genitourinary: pain with urination, blood in urine, frequent bladder infections

abnormal vaginal bleeding or discharge

Last period ______

Breasts:breast lump, nipple discharge,pain in breast

Musculoskeletal: unusual muscle or joint pain, anything that limits your activity

Neurologic: frequent headaches, fainting, blackouts, seizures, weakness, tingling, tremors

Psychiatric: depression, unusual anxiety, history of taking psychiatric medications (name of meds with approximate dates taken)

Student signature______Date______

5/04