Medical History Form

MEDICAL HISTORY FORM FULL NAME: DO YOU: Smoke? Drink Alcohol? Drink Coke? Drink Coffee?

BIRTHDAY:

Yes Yes Yes Yes

Packs per day: Drinks per day: Liters per day: Cups per day:

LIST THE MEDICATIONS YOU ARE NOW TAKING:

LIST ANY ALLERGIES YOU HAVE TO DRUGS, FOOD OR OTHER ITEMS:

ARE YOU CURRENTLY UNDER MEDICAL CARE FOR ANY REASONS? Yes Please explain: WOMEN ONLY: Age when menstrual periods began: Are your periods regular? How many days do your periods last? How many times have you been pregnant? How many children born alive? PRIMARY CARE PHYSICIAN: Name: Address and City: Phone: PAST PSYCHIATRIC/MENTAL HEALTH CARE: Therapist’s Name: For How Long and When: LIST ALL OPERATIONS: Operation Performed

Year

Hospital

No

LIST ALL TIMES YOU HAVE BEEN ADMITTED TO A HOSPITAL OVERNIGHT (EXCEPT FOR C Reason Hospitalized Year Hospital

DOES ANY RELATIVE (PARENTS, High blood pressure: Stroke: Cancer: Emphysema: Ulcers: Mental Illness: Other Serious Illness:

SIBLINGS, GRANDPARENTS, CHILDREN) HAVE HAD AN No Kidney Disease: No Bleeding Tendencies: No Seizures: No Heart Disease: No Sugar Diabetes: No

HAVE YOU HAD ANY OF THE FOLLOWING ILLNESSES? Measles: No Diabetes: Rubella (German Measles): No Goiter, Thyroid Disease: Chickenpox: No Hives: Mumps: No Allergies: Whooping Cough: No Eczema: Scarlet Fever: No Mono: Tonsillitis: No Rheumatic Fever: Diphtheria: No Poliomyelitis: Asthma: No Pleurisy: Glaucoma: No Bronchitis: Cancer: No Influenza: Angina Pectoris: No Tuberculosis: Ulcer: No Phlebitis: Bladder or Kidney Infection: No Other Serious Illness: PLEASE LIST THE DATE AND RESULT (IF KNOWN) OF YOUR LAST, X-ray: EKG: Blood Count: Date of last examination by a doctor:

TORY FORM Date:

10/16/2009 No Yes

# Years smoked:

EMS:

S?

How Often?

Doctor

RNIGHT (EXCEPT FOR CHILDBIRTH): Doctor

ILDREN) HAVE HAD ANY OF THE CONDITIONS LISTED BELOW: No Asthma: No No Tuberculosis: No No Colitis: No No Anemia: No No Gout: No

,

No No No No No No No No No No No No No

Typhoid: Malaria: Tropical Diseases: Hepatitis: Venereal Disease: Seizures: Meningitis: Ear Infections: Heart Murmur: High Blood Pressure: Low Blood Pressure: Heart Attack: Kidney Stones:

No No No No No No No No No No No No No

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Follow the steps to enable your Medical History Form. >>

Your Medical History Form is ready to use. Following steps are for online use.

2)

Visit the site below: http://www.spreadsheetweb.com/getting_started.htm You will only need the username and password to create your Medical History Form.

3)

Visit the site below: https://www4.spreadsheetweb.com/SpreadsheetWEB// Login to page with your new account information.

4)

Click "Add Web Application" to upload this file. Your Medical History Form will be created automatically. You can simply use the Medical History Form from that link or place it on your website.

Online forms will contain a "Save" button. Each time a form is filled and saved, the form will be saved on th Hence, you can create a collection of Medical History forms saved by the names. >>

Your Medical History Form will look like:

http://www1.spreadsheetweb.com/SpreadSheetWeb/Output.aspx?ApplicationId=24d9e2e4-128a-4757-be92 >>

In order to see more online applications created with PSW you can check the link below: http://www.spreadsheetweb.com/demos.htm

Copyright (c) 2009 Pagos, Inc. http://www.pagos.com/

y Form.

created automatically.

e form will be saved on the "Data" tab.

24d9e2e4-128a-4757-be92-e96be55967e4