Personal Medical History of: ____________ Date:_______

Please USE PRINTOUT To Make Copies for ALL family members.    (Form questions from www.acep.org)
   
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) __________________________________________________________________________________________________
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Drug sensitivity and allergies (describe):________________________________________________________________
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Food or other sensitivity &/or allergies, &/or special diet (describe):_________________________________________
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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)
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Have you had or been advised to have a surgical operation within the last five years? (describe)
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Date of last physical:________________________ Date of last tetanus shot: __________________________
Any other special medical information:_________________________________________________________
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Family history — list important medical problems of your parents:__________________________________
Mother:___________________________________Father: ________________________________________