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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 D:\769841611.doc