More examples in Healthcare/Healthcare Forms
Standard Medical History Form 93 Example
SmartDraw includes thousands of professional-looking examples like this Standard Medical History Form 93 that you can easily download, edit and customize to make your own in just minutes.
Text in this example:
11. FEMALES ONLY CHECK EACH ITEM YES NO DON'T
KNOW DATE OF LAST MENSTRUAL PERIOD DATE OF LAST PAP SMEAR DATE OF LAST MAMMOGRAM Treated for a female disorder Change in menstrual pattern CHECK EACH ITEM. IF "YES" EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER ITEM YES NO 12. Have you been refused employment or been unable to hold a job or stay in school because of: a. Sensitivity to chemicals, dust, sunlight, etc. b. Inability to perform certain motions. c. Inability to assume certain positions. d. Other medical reasons (If yes, give reasons.) 13. Have you ever been treated for a mental condition? (If yes, specify when, where, and give details.) 14. Have you ever been denied life insurance? (If yes, state reason and give details.) 15. Have you had, or have you been advised to have, any operation. (If yes, describe and give age at which occurred.) 16. Have you ever been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.) 17. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illnesses? (If yes, give complete address of doctor, hospital, clinic, and details.) 18. Have you ever been rejected for military service because of physical, mental, or other reasons? (If yes, give date, reason for ejection.) 19. Have you ever been discharged from military service because of physical, mental or other reasons? (If yes, give date, reason, and type of discharge; wether honorable, other than honorable, for unfitness or unsuitability.) 20. Have you ever received, is there a pending, or have you ever applied for pension or compensation for existing disability? (If yes, specify what kind, granted by whom, and what amount, when, why.) 21. Have you ever been arrested or convicted of a crime, other than minor traffic violations. (If yes, provide details.) 22. Have you ever been diagnosed with a learning disability? (If yes, give type, where, and how diagnosed.) 23. LIST ALL IMMUNIZATIONS RECEIVED
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 authorize any of the doctors, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable by fine and/or imprisonment. 24a. TYPED OR PRINTED NAME OF EXAMINEE
24b. SIGNATURE 24c. DATE NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY". 25. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in items 7 through 11. Physician may develop by interview any additional medical history deemed important, and record any significant findings here.)
26a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER
26b. SIGNATURE 26c. DATE STANDARD FORM 93 BACK NO. OF ATTACHED SHEETS: MEDICAL RECORD REPORT OF MEDICAL HISTORY DATE OF EXAM
NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons 1. NAME OF PATIENT (Last, first, middle)
2. IDENTIFICATION NUMBER
3. GRADE
4a. HOME STREET ADDRESS (Street or RFD; City or Town; State; and ZIP Code)
5. EXAMINING FACILITY
4b. CITY
4c. STATE
4d. ZIP CODE
6. PURPOSE OF EXAMINATION
7. STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)
a. PRESENT HEALTH
b. CURRENT MEDICATION REGULAR OR INTERM. c. ALLERGIES (Include insect bites/stings and common foods) d. HEIGHT
e. WEIGHT
8. PATIENT'S OCCUPATION
9. ARE YOU (Check one)
RIGHT HANDED LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON'T
KNOW CHECK EACH ITEM YES NO DON'T
KNOW Household contact with anyone with tuberculosis Shortness of breath Bone, join or other deformity Tuberculosis or positive TB test Pain or pressure in chest Loss of finger or toe Blood in sputum or when coughing Chronic cough Painful or "trick" shoulder
or elbow Excessive bleeding after injury or dental work Palpitation or pounding heart Recurrent back pain or any
back injury Suicide attempt or plans Heart trouble "Trick" or locked knee Sleepwalking High or low blood pressure Foot trouble Wear corrective lenses Cramps in your legs Nerve Injury Eye surgery to correct vision Frequent indigestion Paralysis (including infantile) Lack vision in either eye Stomach, liver or intestinal trouble Epilepsy or seizure Wear a hearing aid Gall bladder trouble or gallstones Car, train, sea or air sickness Stutter or stammer Jaundice or hepatitis Frequent trouble sleeping Wear a brace or back support Broken bones Depression or excessive worry Scarlet fever Adverse reaction to medication Loss of memory or amnesia Rheumatic fever Skin diseases Nervous trouble of any sort Swollen or painful joints Tumor, growth, cyst, cancer Periods of unconsciousness Frequent or severe headaches Hernia Parent/sibling with diabetes, cancer, stroke or heart disease Dizziness or fainting spells Hemorrhoids or rectal disease Eye Trouble Frequent or painful urination X-ray or other radiation therapy Hearing loss Bed wetting since age 12 Chemotherapy Recurrent ear infections Kidney stone or blood in urine Asbestos or toxic chemical exposure Chronic or frequent colds Sugar or albumin in urine Plate, pin or rod in any bone Severe tooth or gum trouble Sexually transmitted diseases Easy fatigability Sinusitis Recent gain or loss of weight
Been told to cut down or criticized for alcohol use Hay fever or allergic rhinitis Eating disorder (anorexia bulimia, etc.) Head injury Arthritis, Rheumatism, or Bursitis Used illegal substances Asthma Thyroid trouble or goiter Used tobacco STANDARD FORM 93
KNOW DATE OF LAST MENSTRUAL PERIOD DATE OF LAST PAP SMEAR DATE OF LAST MAMMOGRAM Treated for a female disorder Change in menstrual pattern CHECK EACH ITEM. IF "YES" EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER ITEM YES NO 12. Have you been refused employment or been unable to hold a job or stay in school because of: a. Sensitivity to chemicals, dust, sunlight, etc. b. Inability to perform certain motions. c. Inability to assume certain positions. d. Other medical reasons (If yes, give reasons.) 13. Have you ever been treated for a mental condition? (If yes, specify when, where, and give details.) 14. Have you ever been denied life insurance? (If yes, state reason and give details.) 15. Have you had, or have you been advised to have, any operation. (If yes, describe and give age at which occurred.) 16. Have you ever been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.) 17. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illnesses? (If yes, give complete address of doctor, hospital, clinic, and details.) 18. Have you ever been rejected for military service because of physical, mental, or other reasons? (If yes, give date, reason for ejection.) 19. Have you ever been discharged from military service because of physical, mental or other reasons? (If yes, give date, reason, and type of discharge; wether honorable, other than honorable, for unfitness or unsuitability.) 20. Have you ever received, is there a pending, or have you ever applied for pension or compensation for existing disability? (If yes, specify what kind, granted by whom, and what amount, when, why.) 21. Have you ever been arrested or convicted of a crime, other than minor traffic violations. (If yes, provide details.) 22. Have you ever been diagnosed with a learning disability? (If yes, give type, where, and how diagnosed.) 23. LIST ALL IMMUNIZATIONS RECEIVED
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 authorize any of the doctors, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable by fine and/or imprisonment. 24a. TYPED OR PRINTED NAME OF EXAMINEE
24b. SIGNATURE 24c. DATE NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY". 25. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in items 7 through 11. Physician may develop by interview any additional medical history deemed important, and record any significant findings here.)
26a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER
26b. SIGNATURE 26c. DATE STANDARD FORM 93 BACK NO. OF ATTACHED SHEETS: MEDICAL RECORD REPORT OF MEDICAL HISTORY DATE OF EXAM
NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons 1. NAME OF PATIENT (Last, first, middle)
2. IDENTIFICATION NUMBER
3. GRADE
4a. HOME STREET ADDRESS (Street or RFD; City or Town; State; and ZIP Code)
5. EXAMINING FACILITY
4b. CITY
4c. STATE
4d. ZIP CODE
6. PURPOSE OF EXAMINATION
7. STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)
a. PRESENT HEALTH
b. CURRENT MEDICATION REGULAR OR INTERM. c. ALLERGIES (Include insect bites/stings and common foods) d. HEIGHT
e. WEIGHT
8. PATIENT'S OCCUPATION
9. ARE YOU (Check one)
RIGHT HANDED LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON'T
KNOW CHECK EACH ITEM YES NO DON'T
KNOW Household contact with anyone with tuberculosis Shortness of breath Bone, join or other deformity Tuberculosis or positive TB test Pain or pressure in chest Loss of finger or toe Blood in sputum or when coughing Chronic cough Painful or "trick" shoulder
or elbow Excessive bleeding after injury or dental work Palpitation or pounding heart Recurrent back pain or any
back injury Suicide attempt or plans Heart trouble "Trick" or locked knee Sleepwalking High or low blood pressure Foot trouble Wear corrective lenses Cramps in your legs Nerve Injury Eye surgery to correct vision Frequent indigestion Paralysis (including infantile) Lack vision in either eye Stomach, liver or intestinal trouble Epilepsy or seizure Wear a hearing aid Gall bladder trouble or gallstones Car, train, sea or air sickness Stutter or stammer Jaundice or hepatitis Frequent trouble sleeping Wear a brace or back support Broken bones Depression or excessive worry Scarlet fever Adverse reaction to medication Loss of memory or amnesia Rheumatic fever Skin diseases Nervous trouble of any sort Swollen or painful joints Tumor, growth, cyst, cancer Periods of unconsciousness Frequent or severe headaches Hernia Parent/sibling with diabetes, cancer, stroke or heart disease Dizziness or fainting spells Hemorrhoids or rectal disease Eye Trouble Frequent or painful urination X-ray or other radiation therapy Hearing loss Bed wetting since age 12 Chemotherapy Recurrent ear infections Kidney stone or blood in urine Asbestos or toxic chemical exposure Chronic or frequent colds Sugar or albumin in urine Plate, pin or rod in any bone Severe tooth or gum trouble Sexually transmitted diseases Easy fatigability Sinusitis Recent gain or loss of weight
Been told to cut down or criticized for alcohol use Hay fever or allergic rhinitis Eating disorder (anorexia bulimia, etc.) Head injury Arthritis, Rheumatism, or Bursitis Used illegal substances Asthma Thyroid trouble or goiter Used tobacco STANDARD FORM 93