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Microsoft word - general_medical_info._revised

General Medical Information

Name: _________________________________Date: ______________Age: __________
PAST MEDICAL HISTORY
YEAR

ILLNESSES
________ ( ) Heart trouble (angina__) (heart attack ___) (Heart failure ___) (Heart murmur __) (valve ________ ( ) High blood pressure ________ ( ) Stroke ________ ( ) Ulcers (stomach ___) (duodenal___) (colon___) ________ ( ) Diabetes (high blood sugar) ________ ( ) Liver disease (hepatitis___) (A___) (B___) (Cirrhosis ___) Other______________________________ ________ ( ) Kidney disease (stones ___) (infections ___) other ____________ ________ ( ) Lung disease (emphysema ___)(TB___)(chronic bronchitis ___)(cancer___) (frequent pneumonia___)(asthma___)Other_______________________ ________ ( ) Blood disorders (anemia___) (leukemia ___) (bleeding tendency ___)
Other _____________________________________________
________ ( ) Eye disease (glaucoma___) Other_______________________
________ ( ) Arthritis (degenerative___) (rheumatoid___) (gout ___)Other___________
________ ( ) Cancer, Type ______________________________________
________ ( ) Psychological difficulties (depression___) (psychosis ___) )Other________
________ ( ) Other major illness_____________________________________________
________ ( ) No major illnesses
YEAR
SURGERIES
________ ( ) Hysterectomy (total___) ( partial___) ________ ( ) Biopsy (result & type__________________________) ________ ( ) Fractures explain_________________________________________ ________ ( ) Other _________________________________________________
MAJOR INJURIES/ ACCIDENTES MAYORES
( ) Auto or cycle accidents:________________________________________________
( ) NO MAJOR INJURIES
HOSPITALIZATIONS:__________________________________________________



MEDICATIONS/MEDICINAS (Names & Dosages,
if you have more please list on the back of the page.)
( ) ________________________________________________________________
( ) ________________________________________________________________
( ) ________________________________________________________________
( ) ________________________________________________________________
( )
Birth Control Pill __________________________________________________
ALLERGIES
Describe Reaction:
( ) Penicillin (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
(rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__) ( ) Keflex (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
( ) Codeine (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
( ) Other ________________________________________________________
( ) None ________________________________________________________
FAMILY MEDICAL HISTORY/HISTORIA MEDICA FAMILIAR
MOTHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____
( ) Deceased / Cause:________________________ Age of death ________
FATHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____
( ) Deceased / Cause:________________________ Age of death ________
SIBLINGS: ( ) Alive & well ( ) Alive but suffers with:________________ Age____
( ) Deceased / Cause:________________________ Age of death ________
Members of my family: (brothers, sisters, grandparents, aunts, uncles) suffer from the following:
( ) Stroke
( ) Diabetes ( ) Back problems ( ) Heart trouble
SOCIAL HISTORY/HISTORIA SOCIAL
1. Married ___, Separated ___, Divorced ___, Widow-Widower____, Single______
No. of children at home ______ No. of children away ______
2. I work as/ am retired from______________________________________________________
3. I drink alcohol: None____ Daily____ Socially______
Beer_____ Wine_____ “Hard drinks”_______
I drink too much_______________________________
Others think I drink too much______
4. I smoke: None____ Cigarettes_____ Pipe________ Cigars____
I smoke_____ packs______ a day, for_____ years.

Source: http://medicalsleep.com/Documents/General_Medical_Info.pdf

Article-c siriwardhana et al (171-182)

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Microsoft word - faq's

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