Diabetes (insulin dependent) q q Chronic/frequent colds or flu q q Stomach, Diabetes (not dependent) q q Hearing loss or trouble q q Gall bladder trouble or …
Monterey Bay Aquarium Research Institute
Medical History 1C
Name: Date of Birth: Age:
Address: Male Female
Day phone: Native language:
In case of emergency, please contact: Personal physician name address:
Relationship:
Check if there is any history in your family of: Date of last physical
examination: Diabetes High blood pressure health
rating: Excellent Good Fair explain on reverse Stroke Heart
disease height: weight lbs:
Tuberculosis Jaundice Do you routinely take prescription drugs?
identify explain Easy bleeding Asthma
Allergy Cancer
Other please explain Do you wear:
corrective eyeglasses contact lenses
hearing aids prosthesis or brace
Past Medical History use space provided on reverse if needed
Yes No Not Sure
Have you consulted physicians, clinics, healers or other practitioners
within the past 5 years
for any condition other than a minor illness? if yes, explain
Have
you ever been treated for a nervous condition or any type of mental
illness? if yes, explain
Have you ever been a patient in any type of hospital? if yes, explain
Do you suffer long-term effects or existing disability due to injury or
accident? if yes, explain
Do you suffer from any allergies/sensitivities to chemicals, foods, dust,
etc ?
Are you unable to perform certain motions/assume positions?
Have you ever:
Lived with anyone diagnosed with tuberculosis?
Coughed up blood?
Bled excessively?
Attempted suicide?
continued on reverse
Have you ever experienced or are you now experiencing any of the following
check all that apply:
Y N Y N Y N
Motion sickness Bronchitis Swollen/painful joints
Dizziness/fainting Tuberculosis Broken bones
Periods of unconsciousness Emphysema Loss of
appendage
Amnesia or loss of memory Chronic cough Gout
Head injury Asthma
Arthritis/rheumatism/bursitis
Frequent or severe headaches Shortness of breath
Limited joint motion
Epilepsy or convulsions Sinusitis Thyroid
trouble
Anemia or blood disorder Ear, nose or throat trouble
Kidney or bladder trouble
Diabetes insulin dependent Chronic/frequent colds or flu
Stomach, liver or intestinal trouble
Diabetes not dependent Hearing loss or trouble
Gall bladder trouble or gallstones
Hepatitis or jaundice Glaucoma/vision loss/ eye trouble
Hernia or intestinal rupture
HIV/AIDS Sexually Transmitted diseases Tumor,
growth, cyst or cancer
Heart disease or trouble High or low blood pressure
FEMALES ONLY
Paralysis/lameness Dental trouble Severe
menstrual cramping/pains
Adverse reaction to foods or drugs Depression or excessive
anxiety Treated for reproductive disorder
Other medical conditions explained:
Have you had any of the following immunizations:
Y N
Y N Y N
Tetanus Measles Diptheria
Smallpox Tuberculosis Malaria
I certify that I have reviewed the foregoing information supplied by me and
that it is true and complete to the best of my knowledge I also certify
that I have disclosed all information concerning any and all pre-existing
medical conditions which may make it risky to participate in an ocean-going
cruise, and I assume any and all risks in order to participate I also
understand that there is limited medical expertise on board an MBARI
vessel Should I require medical attention, I hereby authorize the
Monterey Bay Aquarium Research Institute to release a transcript to any
medical experts in attendance, whether on board or shoreside, for the
purpose of providing medical advice for treatment for medical problems
which could occur
Participant Signature Date
Source:hsv.k12.al.us
