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Medical History Form 1

This form is provided by Nova Southeastern University Health Care Center.

Medical History Form 1
Medical History Form 1
NOVA SOUTHEASTERN UNIVERSITY HEALTH CARE CENTER
PATIENT HISTORY FORM
Patient’s Name: _______________________________________ Today’s Date: _______________________________
Social Security Number: ________________________________ Date of Birth: ________________________________
Past Medical History
Previous Physician’s name: ______________________________ Date of last exam: ____________________________
Have you ever been hospitalized
Yes No If yes, what for _____________________________
Have you ever been tested for hepatitis A, B or C Yes No Which hepatitis virus___________________
Have you been vaccinated for hepatitis B Yes No If yes, date vaccine series completed _____________
Have you been vaccinated for hepatitis A
Yes No If yes, date vaccine series completed _____________
Last Tuberculosis (TB) Screening _________________________ Result of TB screening: Positive Negative
If positive TB screen, date of last chest x-ray: _________________ Result of chest x-ray:
Positive Negative
Have you had a sexually transmitted disease Yes No Diagnosis: __________________________________
Which of the following conditions are you currently being treated or have been treated for in the past (please check)
Heart disease / Murmur / Angina Shortness of breathe Eye disorder / Glaucoma Diabetes
High cholesterol Asthma Seizures Kidney / Bladder problems
High blood pressure Lung problems / cough Stroke Liver problems / Hepatitis
Low blood pressure Sinus problems Headaches / Migraines Arthritis
Heartburn (reflux) Seasonal allergies Neurological problems Cancer
Anemia or blood problems Tonsillitis Depression / Anxiety Ulcers/colitis
Swollen ankles Ear problems Psychiatric care Thyroid problems
Please describe any current or past medical treatment not listed above
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Please list your past surgeries
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Allergies
Are you allergic to penicillin or any other drugs
Yes No
Please list: ___________________________________________________________________________________________
Medications
Please list: ___________________________________________________________________________________________
____________________________________________________________________________________________________
PLEASE COMPLETE REVERSE SIDE J
Medical History Form 1
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