Download Application for Election to Board of Directors

 CARING HEALTH CENTER 1049 Main St., 860 Boston Rd. & 532 Sumner Ave., Springfield, MA - (413) 739-1100
Medical History
Patient Name
Last
First
Middle Initial
Date of Birth
Circle the appropriate answer. If you are not sure of an answer please write "Don't Know" on the line after the question.
1.
Physicians Name
Address
2. Are you under a physician's care?
Since when?
Why?
3. When was your last complete physical exam?
4. Are you taking any prescribed or non-prescription medications?
5. Are you allergic to any medications?
6. Do you have any other allergies?
7. Do you have any problems with penicillin, antibiotics, anesthetics or other medications?
8. Are you sensitive to latex?
9. Are you pregnant or suspect you may be?
If YES, what is your due date?
10. Do you use any birth control medications?
11. Have you ever been treated for or been told you might have heart disease?
12. Do you have a pacemaker or an artificial heart valve implant?
13. Have you ever had rheumatic fever?
14. Are you aware of any heart murmurs?
15. Do you have high or low blood pressure?
16. Have you ever had a serious illness or major surgery?
If so, explain
17. Have you ever had radiation treatment, chemo treatment for tumor, growth or other condition?
18. Do you have inflammatory diseases, such as arthritis or rheumatism?
19. Do you have any artificial joints / prothesis?
20. Do you have any blood disorders such as anemia, leukemia, etc.?
21. Have you ever bled excessively after being cut or injured?
22. Do you have any stomach problems?
23. Do you have any kidney problems?
24. Do you have any liver problems?
25. Are you diabetic?
26. Do you have asthma?
27. Do you have epilepsy or seizure disorders?
28. Have you tested HIV positive?
29. Do you have AIDS?
30. Have you had or do you test positive for hepatitis?
31. Do you or have you had T.B. (tuberculosis)?
32. Do you smoke, chew, use snuff or any other form of tobacco?
33. Do you consume alcoholic beverages?
34. Do you habitually use controlled substances?
35. Have you had psychiatric treatment?
36. Have you taken the prescription drugs - fenfluramine, fenfluramine combined with phentermine
(fen-phen), dexfenfluramine (redux) or other weight loss products?
37. Do you have any disease, condition, or problem NOT listed?
If so, explain
38. Is there anything else we should know about your health that we have not covered on this form?
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
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No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
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No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
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No
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No
No
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No
No
No
Yes
Yes
No
No
I certify to the best of my knowledge that the above information is complete and accurate.
Patient/Guardian Signature
Date
Reviewed By (initials)
Date
Created on 5/17/17 7:39 PM