Download Medical History - UC Davis Safety Services

UC Davis Occupational Health Services
Medical History for New Patients
Name: _____________________________________________ SS#:________________________
DEPT _______________________________Phone # __________________DOB:_____________
Address_________________________________________________________________________
Medical History
 Last Tetanus Booster: Year ________
 Hepatitis B Immunization: Year______ Hepatitis B Titer? No Yes If yes what were results?___________
 Last TB Screen Test: Year _______ Positive
Negative
Never tested
History of active Tuberculosis
Are you currently taking medications?
No
Yes
(If yes, list below)
_____________________________________________________________________________________________
Do you have any allergies to any medicines?
No
Yes
(If yes, list below)
_____________________________________________________________________________________________
Have you had any other (non-allergic) reactions or other problems with medicines? No Yes (If yes, list below)
_____________________________________________________________________________________________
Have you had any surgeries? No
Yes (If yes, list below)
_____________________________________________________________________________________________
Have you had any hospitalizations? No
Yes (If yes, list below)
_____________________________________________________________________________________________
Cardiac or circulatory problems?
 High Blood Pressure
 Heart attack
 Heart murmur
 Irregular heart beat
 High cholesterol
No
Yes
(If yes, circle all that apply)
 Varicose Veins
 Swelling of feet or legs
 Blood disorder or anemia
 Bleeding disorder
 Other __________________________________
Lung or Respiratory problems?
No
Yes
(If yes, circle all that apply)
 Asthma
 Bronchitis or Chronic cough
 Pneumonia
 Ever smoked cigarettes/other substances? What type_________________ age started______ age stopped_____
 Other ____________________________________________________________________________________
Endocrine, “glandular”, or “hormone” problems?
 Diabetes
 Thyroid problem
No
Yes
(If yes, circle all that apply)
Intestinal or abdominal problems?
No
Yes
(If yes, circle all that apply)
 Liver Problems
 Hernia or "rupture"
 Have you had any abdominal operations?
No
Yes
(If yes, list below)
__________________________________________________________________________________________
 Ulcers or colitis
 Other_____________________________________________________________________________________
PLEASE TURN FORM OVER TO COMPLETE
Dermatologic or skin problems?
No
Yes
(If yes, circle all that apply)
 Psoriasis
 Eczema
 Contact Dermatitis
 Other chronic skin problems: __________________________________________________________________
Eye problems?
No
Yes
 Eye injury or infection
 Wear glasses or contacts
 Color blindness
 Glaucoma
(If yes, circle all that apply)
Ear and upper respiratory problems?
No
Yes
(If yes, circle all that apply)
 Hearing loss or perforated ear drum
 Chronic or frequent colds
 Allergies to dust, pollen, etc.
 Other_____________________________________________________________________________________
Nervous system problems?
No
Yes
(If yes, circle all that apply)
 Chronic headache
 Stroke
 Seizure
 Fainting spells or loss of consciousness
 Muscle weakness or paralysis
 Other_____________________________________________________________________________________
Orthopedic (bone muscle or joint) problems?
No
Yes
(If yes, circle all that apply)
 Fractures
 Back pain, sciatica or herniated disc injury or surgery
 Neck strain or whiplash or neck surgery
 Knee injury (i.e. torn cartilage or torn ligament, kneecap problems)
 Carpal tunnel syndrome
 Wrist or forearm problems
 Tennis elbow
 Shoulder dislocation rotator cuff
 Arthritis
 Other_____________________________________________________________________________________
Other medical problems?
No
Yes
(If yes, circle all that apply)
 Tumor (benign or cancer)
 Kidney or bladder problems
 Drug or alcohol problem
 Have you been under a doctor's care for medical or emotional problems during the past 5 years?
Work history: Date last worked: ________________
 Medical discharge from military?
No
Yes
 Have you had a work-loss injury?
No
Yes
 Have you received compensation for an industrial injury? No
Yes
 Do you have a permanent disability rating from an industrial injury?
No
No
Yes
Yes
PATIENT SIGNATURE_________________________________________________DATE___________________
Rev 04/11
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