Diabetes Thyroid Disease Kidney Disease. Heart Attack By-pass Surgery Heart Failure Diabetes. Stroke. Cancer. Type/location. Osteoporosis. Thyroid …
Faculty/Staff Health History
Name __________________________________ Todays Date
______________ Dept: _________
Age ___________ Date of Birth ___/___/_____ Work Phone: ______
Cell Phone: _____________
Sex ___ Female ____ Male Marital Status: ____ Married
____ Single ____ Separated
____ Divorced ____ Widow/er
What is your current health concern?
_________________________________________________________________
_________________________________________________________________
______________________________________
PAST MEDICAL HISTORY: Circle the conditions doctors have
followed you for in the past:
High Blood Pressure High Cholesterol Liver Disease
Diabetes Thyroid Disease Kidney
Disease
Heart Attack By-pass Surgery Heart Failure
Heart Murmur Mitral Valve Prolapse Stroke
Seizures/Epilepsy Stomach Problems
Intestinal Problems
Reflux Disease Glaucoma Psychiatric Illness
Arthritis Cancer: Type and location
____________________
Abnormal Pap test Other:
____________________________________
Have you ever had: Yes No For
Females:
Positive tuberculosis test? ____ ____ Last
Menstrual period: _________
Rheumatic Fever? ____ ____ Are periods
regular? __________
Blood transfusion? ____ ____ of
pregnancies _____________
If yes, when? _____________ Complications
_____________
Number of children
_________
Please list any operations or past hospitalizations including C-
sections:
__________________ _____________________
_____________________
__________________ _____________________
_____________________
Please list any drug allergies/reactions:
____________________________________
_________________________________________________________________
______
Please list all current medications include vitamins,
herbal
and health food preparations:
__________________ _____________________
_____________________
__________________ _____________________
_____________________
__________________ _____________________
_____________________
FAMILY HISTORY - Has anyone in your family had any of the
following?
Disease/Condition Mother Father
Maternal Paternal Brother/ Other
Gparents Gparents Sister
|Hypertension/ | | | | | | |
|High Blood | | | | | | |
|Pressure | | | | | | |
|Heart Attack/ | | | | | | |
|Heart Surgery | | | | | | |
|Diabetes | | | | | | |
|Stroke | | | | | | |
|Cancer | | | | | | |
|Type/location | | | | | | |
|Osteoporosis |
| | | | | |
|Thyroid | | | | | | |
|Problems | | | | | | |
|Mental | | | | | | |
|Illness | | | | | | |
|Glaucoma | | | | | | |
|Other | | | | | | |
PREVENTIVE CARE: When was your last:
Tetanus Booster ________________
Source:dowjones.com
