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Student/University Health Services and will not be
released to anyone without your knowledge or consent.
ETSU
STUDENT/UNIVERSITY HEALTH SERVICES
Please Print Legibly in INK
Social Security Number
PO BOX 70675
Johnson City, TN 37614
Form will not be processed without this number
REPORT OF MEDICAL HISTORY
ETSU ID#: E
PLEASE COMPLETE THIS FORM AND BRING WITH YOU FOR YOUR APPOINTMENT!
LAST NAME
FIRST NAME
HOME ADDRESS (NUMBER AND STREET)
SINGLE
CITY
MARRIED
STATE
WIDOWED
OTHER
STATE OF
HEALTH
DATE OF BIRTH
PHONE NUMBER
DO YOU HAVE INSURANCE?
YES
NO
Have any of your grandparents, parents or siblings ever
had any of the following diagnosed illnesses?
Immediate Family History:
AGE
ZIP CODE
RELATIONSHIP
DIVORCED
F
MIDDLE
EMERGENCY CONTACT: NAME AND ADDRESS
MARITAL STATUS:
M
SEX:
AGE OF
DEATH
OCCUPATION
CAUSE OF DEATH
YES
FATHER
TUBERCULOSIS
MOTHER
DIABETES
NO
RELATIONSHIP
KIDNEY DISEASE
BROTHERS
HEART DISEASE
ARTHRITIS
STOMACH DISEASE
ASTHMA
SISTERS
MIGRAINE
EPILEPSY,
CONVULSIONS
CANCER
(what type)
THYROID
DISEASE
PERSONAL HISTORY Please answer all Questions. Comment on all positive answers in space provided or on back of this sheet.
YES
ALLERGIES TO MEDICATIONS
(DESCRIBE ALL REACTIONS)
NO
COMMENTS:
Additional medication allergies and description of allergic response:
PENICILLIN
SULFONAMIDES
SERUM
OTHER
ALLERGIES TO FOODS
A. Has your physical activity been restricted
during the last five years due to a chronic
condition? (Give reason and durations)
B. Have you been exposed to violence in the
home, school or community?
C. Have you received treatment or counseling for
a nervous condition, personality or character
disorder, or emotional problem?
D. Have you had any chronic illnesses or injuries
or been hospitalized other than already noted?
(Give Details)
E. Have you consulted or been treated by clinics,
physicians, healers, or other practitioners within
the past five years? (Other than for routine
checkups)
List food allergies:
04/30/2012js
PERSONAL HISTORY, CONTINUED
YES
NO
COMMENTS:
F. Have you been rejected for or discharged from
military service because of physical, emotional, or
other reasons? If yes, give reasons.
Date of last vision exam:
G. List Date of last pap smear:
Date of last dental exam:
PERSONAL HISTORY: Have you been diagnosed with any of the following illnesses?
HAVE YOU HAD?
YES
NO
YES
NO
YES
NO
YES
Rheumatic Fever
Worry or
Nervousness
Heart Murmur
Dizziness, Fainting
Scarlet Fever
Frequent Anxiety
High/Low Blood Pressure
Weakness, Paralysis
Chicken Pox
Frequent
Depression
Palpitations (heart)
MALES ONLY:
Measles
Insomnia
Disease/Injury of Joints
Testicular Pain
/Swelling
Mumps
Recurrent
Headache
Arthritis
Penile Discharge
German Measles
Recurrent Colds
Ear, Nose, Throat Trouble
Genital Warts
Malaria
Head Injury with
Unconsciousness
Back Problems
Painful Urination
Gum or Tooth
Trouble
Hay Fever/Asthma
Tumor, Cyst
FEMALES
ONLY:
Sinusitis
Tuberculosis
Stomach /Intestinal Trouble
Abnormal Pap
Eye Trouble
Shortness of
Breath
Cancer
Irregular Periods
Epilepsy,
Convulsions
Chronic Cough
Jaundice
Severe Cramps
Surgery:
Rupture Hernia
Sexually Transmitted Diseases
Excessive Flow
Appendectomy
Migraine
Headaches
Urinary Tract Infections or
kidney problems/disease
Vaginal Infections
Tonsillectomy
Diabetes
Gallbladder Trouble or
Gallstones
Genital Warts
Hernia Repair
Low Blood Sugar
Recurrent Diarrhea
Ovarian Cysts or
Tumors
Other Surgery
Known heart
problems
Recent Gain or Loss of Weight
Other
Vein Problems,
Blood Clots
Pain/Pressure in
Chest
“Trick” knee, Shoulder, etc.”
Other
NO
Comments:
Patient’s Signature:
Date:
Reviewed by:
Date:
04/30/2012js