Personal Medical History of: ____________ Date:_______ |
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Please USE PRINTOUT To Make Copies for ALL family members. (Form questions from www.acep.org) |
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Name: ______________________________________ Birthdate:_____________________________________________ In Case of Emergency Please Contact:__________________________________________________________________ Physician:_____________________________________ Telephone numbers:___________________________________ _____________________________________________ ____________________________________________________ Dentist:_______________________________________ ___________________________________________________ Eye doctor:____________________________________ ____________________________________________________ Other: ______________________________________ _____________________________________________________ Pharmacy Number: ______________________________ _________________________________________________ Your current medical condition:________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ List prescription and non-prescription medications (and vitamins) you are taking: (with dosage amount) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _________________________________________________________________________________________________ Drug sensitivity and allergies (describe):________________________________________________________________ _________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Food or other sensitivity &/or allergies, &/or special diet (describe):_________________________________________ __________________________________________________________________________________________________ Name of health insurance carrier:____________________ Group no.:___________ ID#__________________________ Health Insurance Carrier Phone# ___________________Address:___________________________________________ Have you ever been told you had one of the following? Lung disorder o yes o no___________________________________ High blood pressure o yes o no______________________________ Heart trouble o yes o no ___________________________________ Nervous disorder o yes o no________________________________ Disease or disorder of the digestive tract o yes o no____________ Any form of cancer o yes o no______________________________ Disease of the kidney o yes o no____________________________ Diabetes o yes o no______________________________________ Arthritis o yes o no_______________________________________ Hepatitis o yes o no_______________________________________ Malaria o yes o no_______________________________________ Disease or disorder of the blood? (describe)______________________________________________________________ Any physical defect or deformity? (describe)______________________________________________________________ Any vision or hearing disorders? (describe)_______________________________________________________________ Any life-threatening conditions? (describe)_______________________________________________________________ Any contagious disorders? (describe)___________________________________________________________________ Have you been treated by a physician or been disabled or hospitalized during the last year? (describe) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have you had or been advised to have a surgical operation within the last five years? (describe) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Date of last physical:________________________ Date of last tetanus shot: __________________________ Any other special medical information:_________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Family history — list important medical problems of your parents:__________________________________ Mother:___________________________________Father: ________________________________________ |
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