Diabetes check-up have been diabetic for six years and your diabetes treatment has been going well. for a diabetes checkup, including cholesterol …
PLEASE RETURN TO: Check
here if previous MCG student [ ]
Student Health Service
Last date enrolled:________ Program_________________
Medical College of Georgia Name
Used___________________________________________
Augusta, Georgia 30912-9070
706721-3448
MEDICAL RECORD INFORMATION CONFIDENTIAL
Name:__________________________________________________________________
_______________________
Last First
Middle Pulse ID
Address:_______________________________________________________________
_______________________
Number Street City
State Zip Telephone
Birthdate:_____________ Birthplace____________ Sex: M[ ] F[ ] Marital
Status: S[ ] M[ ] Other[ ]
Emergency Notification: Please list two
1 Name:______________________________________________
Relationship:_________________
Address:____________________________________________________________________
______ Business Phone:_______________ Home
Phone:_____________
2 Name:______________________________________________
Relationship:_________________
Address:____________________________________________________________________
______ Business Phone:_______________ Home Phone:_____________
I have been accepted into the school of Check One: MEDICINE, DENTAL,
NURSING ,
ALLIED HEALTH:
Department Check One: Rad Tech, Dental Hygiene, Med Tech, Occ Therapy,
Phy Assist ,
Nuc Med, HIA, Resp Therapy, PharmD, Child Life, Ultrasound Radiography
GRADUATE: Please Print - Department:___________________________________
Nursing, Phy Therapy, Cell molecular, etc
HEALTH HISTORY: Detail of YES answers - use additional paper if needed -
identify and include pertinent information
Have you ever had or been treated for:
YES NO
YES NO
|1 Serious disease of eyes, | [ ]| 20 Infectious | [ ]|
|ears, nose, or throat? |[ ] |mononucleosis? |[ ] |
|2 Frequent or severe | [ ]| | |
|headaches, convulsions, severe|[ ] |21 Recurrent fever |[ ] |
|head injury? | |blisters? |[ ] |
|3 Lung disease, tuberculosis,|[ ] |
| |
|persistent cough? |[ ] |22 Mumps? |[ ] |
| | | |[ ] |
|4 High blood pressure, |[ ] | | |
|rheumatic fever, heart murmur |[ ] |23 Chicken pox |[ ] |
|or blood vessel disease? | | |[ ] |
| |[ ] | | |
|5 Jaundice, hepatitis, |[ ] |24 Malaria |[ ] |
|intestinal bleeding, ulcer | | |[ ] |
|colitis, gall bladder disease?| | | |
| | | | |
|6 Sugar, albumin, or blood in|[ ] | 25 Tuberculosis? |[ ] |
|urine; cystitis, nephritis, |[ ] | |[ ] |
|kidney stones? | | | |
|7 Diabetes, thyroid disease |[ ] | 26 Human Immuno |[ ] |
|or other endocrine disorder? |[ ] |deficiency virus? |[ ] |
| | | 27 Did your Mother | |
|8 Anemia, or other disorders |[ ] |receive DES
|[ ] |
|of the blood? |[ ] |Diethystilbesterol while |[ ] |
| | |pregnant | |
| | |with you? | |
|9 Deformity, lameness, |[ ] | 28 Sexually transmitted |[ ] |
|paralysis, arthritis, gout, |[ ] |diseases? |[ ] |
|disc problems, other disorders| | | |
|of muscles, bones, or joints? | | | |
|10 Hay fever, asthma, hives, |[ ] | 29 Have you been treated |[] [|
|other allergies? |[ ] |for a nervous or mental |] |
| | |disorder? | |
|11 Severe acne, eczema, other| [ ]|30 Do you consider |[ |
|skin disorders? |[ ] |yourself more nervous than |[ ] |
| | |the average person? |[ ] |
|12 Cancer, other tumors? |[ ] |31 Are you self-conscious |[ ] |
| |[ ] |in the company of others to|[ ] |
| | |an annoying | |
| | |extent?
| |
|13 Significant emotional or |[ ] |32 Does uncertainty or |[ ] |
|psychological difficulties? |[ ] |doubt about yourself and |[ ] |
| | |your activities bother you?| |
|14 Any operations or serious |[ ] |33 Have you ever undergone|[ ] |
|injuries? List dates ____ |[ ] |psychotherapy? |[ ] |
|15 Other hospitalizations, |[ ] |34 Men only: Have you |[ ] |
|for medical or psychiatric |[ ] |ever had testicular lumps? |[ ] |
|care? | | | |
|16 Allergic reactions to |[ ] |35 Women only: Any |[ ] |
|penicillin or other medicines?|[ ] |disorders of menstrual |[ ] |
| | |periods or of the female | |
| | |organs or breasts? | |
|17 Allergic reactions to |[ ] |36 Do you take |[ ] |
|insect bites or to food? |[ ] |birth-control pills? |[ ] |
|18 X-ray therapy to the head |[ ] |37 Have you had a pelvic |[ ] |
|or neck? |[ ] |exam and Pap smear? If so |[ ] |
| | |SEND copy of |
|
| | |test results for most | |
| | |recent | |
|19 Are you adopted? | |
|[ ] [ ] | |
PLEASE RESPOND TO THE FOLLOWING:
ALLERGIES:__________________________________________________________________
________________________________________________________
DRUG
ALLERGIES:__________________________________________________________________
___________________________________________________
CURRENT
MEDICATIONS:________________________________________________________________
_______________________________________________
MEDICAL
PROBLEMS:___________________________________________________________________
________________________________________________
PERSONAL HABITS
PLEASE CHECK THE APPROPRIATE RESPONSE:
A Do you smoke? yes no
B If yes, how many packs per day? less than one between one and two two
packs or more
C Do you drink alcohol? yes no
D If yes, how often? daily only on weekends two or three drinks a week
donly on special occasions
E Do you use recreational drugs? no I have in
the past yes, occasionally
yes, often
F I use over-the-counter drugs ie, Tylenol, Sominex, Ex-Lax, Allerest,
etc: never sometimes boccasionally coften
G Are you presently, or have you been on a weight loss diet yes no
H Are you presently, or have you recently been on a diet intended to help
you gain weight? yes no
I How often do you exercise or participate in sports? never once a week 2
or 3 times a week more than 3 times
J Do you use a seat belt? always never
FAMILY HISTORY
|NAME |AGE |OCCUPATION |STATE OF HEALTH|AGE AND CAUSE OF |
| | | | |DEATH |
|FATHER |
|MOTHER |
|BROTHERS |
|SISTERS |
Have any close relatives had at any timecircle any that apply and give
details High Blood pressure, heart disease, stroke, bleeding disorder,
diabetes, peptic ulcers, kidney disease, epilepsy, migraine, arthritis,
cancer, tuberculosis, asthma or other allergies, mental
illness:
____________________________________________________________________________
________________
____________________________________________________________________________
________________
STATEMENT AND SIGNATURE BY PATIENT:
All statements in this health form are true to the best of my
knowledge and I have no
abnormality, limitation or restriction not mentioned in this record I
understand that
this form is a part of my medical record and agree to notify the
Student Health Service
of any change that occurs in my physical or mental health in a timely
fashion while I
am a student at MCG In an emergency situation, I give permission for
such diagnostic,
therapeutic, and operative procedures as may be deemed necessary to
preserve life or
good health
_______________________________________________________________________
______
PATIENT SIGNATURE
DATE
