Medical History Form

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7/9 EXAMPLES

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11. FEMALES ONLY
CHECK EACH ITEM
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
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
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