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Medical History

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Medical History for all household members.

Published in: Health & Medicine
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Medical History

  1. 1. HEALTH STATUS (TO BE COMPLETED BY EACH HOUSEHOLD MEMBER) NAME: DATE OF BIRTH: MEDICAL HISTORY Have you had a history of, or treatment for, any of the following? NO YES NO YES NO YES Tuberculosis Depression Alcoholism Cancer Seizures Asthma Severe Arthritis Heart Condition Chronic Headaches Chronic Kidney Mental/Emotional Chronic Fatigue Condition Problems Colitis Ulcers Insomnia Eczema Hemophilia Allergies Hayfever Diabetes Other: _______________ Have you ever received treatment for mental problems? Yes or No If yes, when?________________________________ From whom? ________________________ Have you taken medication for mental or emotional problems? Yes or No Latest Revision 06/01/09 Page 1 of 3 file: CPA Policies/Forms/Parent Files/Medical History
  2. 2. When? Drugs Prescribed ____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Have you ever gone to counseling for emotional or family problems? Yes or No If yes, describe: HEALTH STATUS Have you ever had a psychological evaluation or battery of psychological test? Yes or No If so, when______________________________________________________________________ List all prescription medications being taken on a regular basis. Medication Reason for Medication _______________________________________________________________________________________ _______________________________________________________________________________________ Date of last visit to doctor and reason. _______________________________________________ ______________________________________________________________________________ List all illness you have had in the past year. ___________________________________ ___________________________________ ___________________________________ Do you have any physical disability? ______ ______ If yes, when and what? _______________ NO YES ______________________________________________________________________________ Have you ever been treated for drug usage? ______ ______ If yes, when and where? NO YES Latest Revision 06/01/09 Page 2 of 3 file: CPA Policies/Forms/Parent Files/Medical History
  3. 3. Have you ever been treated for alcoholism? ______ ______ If yes, when and where? NO YES A statement may be needed from a physician, psychologist, or counselor concerning you and/or your child’s past or current physical, mental, or emotional condition. Are you willing to give permission for release of such information if necessary? ______ ______ __________________________________ ___________ NO YES Signature Date Latest Revision 06/01/09 Page 3 of 3 file: CPA Policies/Forms/Parent Files/Medical History

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