Read NSU Healthcare Center Patient Medical History Form text version

NOVA SOUTHEASTERN UNIVERSITY HEALTH CARE CENTER PATIENT HISTORY FORM

Patient's Name: _______________________________________ Social Security Number: ________________________________ Past Medical History Previous Physician's name: ______________________________ Have you ever been hospitalized? Have you ever been tested for hepatitis A, B or C? Have you been vaccinated for hepatitis B? Have you been vaccinated for hepatitis A? Date of last exam: ____________________________ If yes, what for? _____________________________ Which hepatitis virus?___________________ If yes, date vaccine series completed _____________ If yes, date vaccine series completed _____________ Result of TB screening: Result of chest x-ray: Today's Date: _______________________________ Date of Birth: ________________________________

Yes Yes Yes Yes

No No No No

Last Tuberculosis (TB) Screening? _________________________ If positive TB screen, date of last chest x-ray: _________________ Have you had a sexually transmitted disease?

Positive Negative Positive Negative

Yes No

Diagnosis: __________________________________

Which of the following conditions are you currently being treated or have been treated for in the past (please check)

Heart disease / Murmur / Angina High cholesterol High blood pressure Low blood pressure Heartburn (reflux) Anemia or blood problems Swollen ankles

Shortness of breathe Asthma Lung problems / cough Sinus problems Seasonal allergies Tonsillitis Ear problems

Eye disorder / Glaucoma Seizures Stroke Headaches / Migraines Neurological problems Depression / Anxiety Psychiatric care

Diabetes Kidney / Bladder problems Liver problems / Hepatitis Arthritis Cancer Ulcers/colitis Thyroid problems

Please describe any current or past medical treatment not listed above ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Please list your past surgeries ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Allergies Are you allergic to penicillin or any other drugs?

Yes No

Please list: ___________________________________________________________________________________________ Medications Please list: ___________________________________________________________________________________________ ____________________________________________________________________________________________________

PLEASE COMPLETE REVERSE SIDE

Social and Preventive History Do you currently smoke or chew tobacco? Yes No How many packs per day? _______________________ Do you drink alcohol, beer, or wine? Yes No How many drinks per week? ______________________ Do you currently drink coffee and/or tea? Do you exercise daily/weekly? Do you use seatbelts while driving?

If no, have you in the past?

Yes No Yes No

If no, have you in the past?

Yes No Yes No Yes No

If yes, how many cups per day? ________________________

Do you wear a helmet while riding a bike?

Yes No

Family History Living Mother Father Sisters Age (or age at death) List serious illnesses __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________

Brothers

Yes Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No

_________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________

Has any member of your family (including children and parents) had any of the following illnesses: Illness Anemia or Blood disease Cancer Diabetes Glaucoma Heart disease High blood pressure HIV disease / AIDS Mental Illness / Depression Stroke Other serious illness Females: Gynecological History How many times have you been pregnant? ______________ Have you had an abnormal Pap Smear? Date of last Pap Smear: ____________________________ Diagnosis: _______________ Follow up: ______________ Diagnosis: ______________________________________ Mammogram results: ______________________________ Biopsy results: ___________________________________ Which family member? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

Have you had a sexually transmitted disease? Date of last mammogram: ____________________________ Have you ever had a breast biopsy?

Yes No Yes No Yes No

By signing below, I hereby certify that to the best of my knowledge all the information I have furnished on this form is complete, true and accurate. Patient/Legal Guardian Signature ____________________________________________ Date ________________

Information

NSU Healthcare Center Patient Medical History Form

2 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

107858


You might also be interested in

BETA
Microsoft Word - Chaudhary and Dantu pdf.doc
DD Form 2807-2, Medical Prescreen of Medical History Report, August 2011
Microsoft Word - 021708 Initial Assessment