Pes.hendricks.k12.in.us

Patient Information and
Medical History
Patient Name____________________
SSN____________________________
Birth date______________________
Phone Number
_______________________________
THE FOLLOWING INFORMATION IS CONFIDENTIAL.
List all Medications which you
If you have any allergies,
currently use and why:
please list them and your reaction here:
(ex. Insulin for Diabetes, Motrin for Arthritis, etc.) (ex. Eggs-rash, Penicillin-short of breath, Dust-congestion, etc.) 1. ______________________________________ 1. ______________________________________ 2. ______________________________________ 2. ______________________________________ 3. ______________________________________ 3. ______________________________________ 4. ______________________________________ 4. ______________________________________ 5. ______________________________________ PAST MEDICAL HISTORY
HAVE YOU EVER HAD OR BEEN TOLD THAT YOU HAD,
(Please provide details for all “Yes” responses in the comment section below)
ANY PERMANENT RESTRICTIONS DUE TO A MEDICAL CONDITION COMMENTS:
Please list all surgeries or hospitalizations and date:
Comments:
(ex. appendectomy 1996, lumbar disc 1994, etc.)
1.____________________________________________
2.____________________________________________ 3.____________________________________________ 4.____________________________________________ Prevention
Tobacco History
Alcohol History
_____Used to drink but stopped in the year_____ _____Have more than one drink/day on average _____Have more than 14 drinks/week on average Has your cholesterol been checked in the last 5 years? Have you had a tetanus booster within the last 10 years? Y N Have you had the Hepatitis B vaccine series? Y N Do you receive yearly flu shots? Y N
Comments________________________________________________________________________________________________
Family History

Has any blood relative in your family, (ie. grandparents, parents, brothers, sisters, etc.)
ever had any of the following diseases, if so please indicate:

No Relationship
Relationship
Diabetes
Tuberculosis
Heart Problems
Sickle Cell Disease
High Blood Pressure
Other____________________________________________
Females Only

Do you get regular PAP smears?
Do you perform regular self breast exams Y N
Please list number of times pregnant _______
When was your last menstrual period?
________
Please list the number of births
To your knowledge, are you pregnant ? Y N
Have you ever had a mammogram? Y N

Comments:

Source: http://pes.hendricks.k12.in.us/modules/groups/homepagefiles/cms/1602099/File/District%20Information/Pt%20Info%20and%20Medical%20History.pdf