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Confidential Medical History University of Nebraska – Omaha, Health Services, HPER Room 102 6001 Dodge Street, Omaha, NE 68182-0301 (402)554-2374 Have you had any of the following? Please check the appropriate box. Heart/Lungs Yes No Asthma Heart Disease Heart Murmur High Blood Pressure Pneumonia Rheumatic Fever/Rheumatic Heart Neurological Yes No Yes No Adrenal Disorders Diabetes Thyroid Disorders Kidneys Kidney or Bladder Disease Kidney Transplant Ears/Eyes/Nose/Throat Yes No Yes No Eye Disorders (other than glasses Hearing Loss Nasal Allergies (Hay fever) Sinus Infections Stomach/Bowel Chronic Colitis Gallbladder Disease Ulcers Irritable Bowel Syndrome Jaundice (other than newborn) Liver, Stomach or Bowel Disease Orthopedics No Yes No Seizures Head Injury Headaches Multiple Sclerosis Muscular Dystrophy Stroke/ TIA Mental Health Yes Yes No Yes No No Anorexia/Bulimia (Eating Disorder) Depression ADD Anxiety During the past month: 1. Have you often been bothered by feeling down, depressed or hopeless? 2. Have you o ften been bothered by little interest or pleasure in doing things? Surgical History/Hospitalizations Arthritis Fractures (History of) Skin Eczema/ Psoriasis Hives Yes Anemia Blood Disorders Cancer Radiation Therapy Thrombophlebitis (Blood Clots) Endocrine Hematology/Oncology Prior Surgery _________________ Appendectomy Ear Tubes Ear Tubes Gallbladder Removal Tonsillectomy Wisdom Teeth Extraction Yes No Infectious Diseases Chicken Pox Hepatitis A B or C HIV Infection Infectious Mononucleosis Malaria Mumps Tuberculosis Sexually Transmitted Diseases Carrier of Infectious Diseases Social History Do you exercise? Do you smoke/use smokeless tobacco? Do you use street drugs? Do you use caffeine? Do you drink alcohol? Other Have you been hit, slapped, kicked or otherwise physically, verbally, or sexually abused by someone? Are you interested in HIV testing? Have you received the HPV (Gardasil) vaccine? (26 & under) OB History (enter #) Pregnancies Miscarriages Live Births Now Living Yes No Yes No Yes No Medications & Allergies Current medications (including birth control pills, acne meds, ect.) Please list medication allergies: Have you had any reactions to bee Yes No stings, dyes, food, latex, etc? If so, what were your symptoms? Previous Hospitalizations Comment on all “yes”, allergies, medications, or any other health issues: Does your immediate family have any of the following? Please check the appropriate boxes. Mother Father Siblings Maternal Family Paternal Family Alcoholism Diabetes Cancer (List type) Heart Disease High Cholesterol Kidney Disease High Blood Pressure Stroke Mental Illness/Depression Other (Please explain) Rev 4/8/13
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