(Must be completed for all initial visits or yearly)
Name
Date
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
REASON
DATE
Pregnant?
Yes No
Planning Pregnancy?
Have you had?
Yes
No
1.
Loss of Consciousness
2.
Frequent headaches
3.
Dizziness of fainting spells
4.
Mental, brain, nervous trouble
5.
Fits, epilepsy, convulsions
6.
Lung disease or emphysema
7.
Asthma, hay fever, sinus
8.
Blindness, color blindness
9.
Ear trouble, decreased hearing
10.
Ringing in the ears
11.
Diabetes, frequent boils
12.
Tuberculosis
13.
Chest pains ro discomfort
14.
Coughing or wheezing
15.
Heart trouble/heart attack/stroke
16.
High blood pressure
17.
18.
Stomach trouble, ulcers
19.
Thinking or sleeping trouble
20.
Gall bladder or liver desease
21.
Yellow jaundice or hepatitis
22.
Blood in stool or urine
23.
Change in bowel habits
24.
Skin deisease or rash
25.
Kidney trouble/stones
Do you smoke?
Do you drink alchohol?
26.
Rupture of hernia
27.
Varicose veins, let ulcers
28.
Rheumatism, arthritis, goul
29.
Deformity, amputation
30.
Stiff joints, trick shoulders, or knees
31.
Back trouble
32.
Scars, identifying marks
33.
Cancer or tumor
34.
Blood disease or anemia
35.
Military service
36.
Rejected for military service
37.
Eye trouble, vision problem(s)
38.
Unusual weight gain or loss
39.
Are glasses adequate?
40.
Ever x-rated? When
41.
Seen a doctor in the last 2 years
42.
Ever rejected for life insurace?
43.
Have you ever ben rejected for employment for medical reasons?
44.
Serious infections
45.
Urine problems
46.
Thyroid, gland disease
47.
Any relative with (TB, diabets, cancer)
48.
Ever seen a counselor, psychiatrist
49.
Tuberculin test
If yes, how much?
If yes, how often?
Are you unable to perform certain motions, assume positions, or lift heavy objects?
Yes No Exercise Routine:
Remarks (indicate item # & Year)
Fill in completely for living and deceased relatives:
RELATION
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Father
Mother
Husband/ Wife (name)
Children (names)
Age of living
Age of death
Cause of Death (If known)
DISEASE
Heart Attach
High BP
Stroke
Kidney Disease
Cancer
Epilepsy
Allergy
Asthma
Glaucoma
Psychiatric Illness
Alchoholism
Specify If Other
WOMEN
Breast problems or breast surgery
Abnormal mammogram
Abnormal pap smear
Vaginal discharge
IIrregular periods of spotting
Recurrent vaginal area rash or
discomfort at time of periods
Pain with intercourse
CONTRACEPTION: (Birth Control Methods)
Tubal Ligation
Condoms and/or foam
Birth control pills
IUD (loop, spring, copper 7 or T, etc.)
Diaphragm
Any other method of contraception
Are you pregnant?
Age at first menstrual period
Date of last mentrual period
Date of period before that
Usual time from beginning of menstrual period to beginning of next in days
Please indicate following numbers:
Pregnancies (total number)
Deliveries (total number)
Premature deliveries
Miscarriages
Abortions
Cesarean sections
Living children
Other surgical procedures dealing with pregnancy