Drexel University
College of Medicine
Drexel Student Health Center
In the tradition of Woman’s Medical College of
Pennsylvania and Hahnemann Medical College
Year of Graduation From Drexel:__________________
Please complete this form in order to ensure proper billing of your services: PLEASE PRINT
Date:
____/_____/_____
Patient Name:_______________________________________________________________________________________
Last
First
MI
Race:______________ Ethnicity:______________________
Other Name/Maiden Name: ___________________________
Address 1:_________________________________________
Address 2:_________________________________________
City, State, Zip:_____________________________________
Home Phone Number:________________________________
Language: _____________________________
Date of Birth: ___________________________
SS #:__________________________________
Sex: (M/F):_____________________________
Email :_________________________________
Cell Phone Number:_______________________
Emergency Contact:
Name:_____________________________________________________
Address 1:__________________________________________________
Address 2:__________________________________________________
City, State, Zip:______________________________________________
Allergies to Medicines, X-Ray Dyes, or Other Substances:
Relationship to Patient:_________________
Home Phone:_________________________
Work Phone:_________________________
 Yes  No
If yes, please list what you are allergic to and type of reactions:__________________________________________________
______________________________________________________________________________________________________
Drug Name (Prescriptions, Over-the-Counter,
Dose Vitamins, Herbs, etc.) Drug Name
Dose
Medications:
Drug
Name
Dose
Drug Name
Dose
_______________________________________
___________________________________
_______________________________________
___________________________________
_______________________________________
___________________________________
_______________________________________
___________________________________
Pharmacy Name:________________________
Phone #____________________________
Address:___________________________________________________________________________
Family History:
Has any member of your family (including parents, grandparents, and siblings) ever had the following:
Illness
Which Family Member(s)
Approx. age when diagnosed
Cancer (describe type)
_____________________________________
_______________________
Hypertension (high blood pressure)
_____________________________________
_______________________
Heart disease
_____________________________________
_______________________
Diabetes
_____________________________________
_______________________
Strokes
_____________________________________
_______________________
Mental disease (anxiety, depression, etc.) _____________________________________
______________________
Drug or alcohol addictions
_____________________________________
______________________
Glaucoma
_____________________________________
______________________
Bleeding diseases
_____________________________________
______________________
*
Osteoporosis
_____________________________________
______________________
Other: ___________________
_____________________________________
______________________
Other:____________________
_____________________________________
______________________
Philadelphia Health and Education Corporation, doing business as Drexel University College of Medicine,
is a separate not-for-profit subsidiary of Drexel University.
Prevention:
Do you wear seatbelts?
Do you wear a bike helmet?
Do you smoke?
Do you drink alcoholic beverages?
Do you drink coffee/tea?
Is there a gun in your home?
If yes, is it out of reach of children and
Unloaded?
Do you use drugs?
Have you engaged in any activity which
has put you at risk of getting AIDS?
 No
 No
 No
 No
 No
 No
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
Do you wish to be tested?
 No  Yes
Have you ever worked with chemicals,
paints, asbestos, or other hazardous
material?
 No  Yes
Are you in a relationship in which you
have been physically hurt (e.g. slapped,
kicked, punched, bruised) by your
partner?
 No  Yes
Do you feel afraid of your partner?
 No  Yes
Do you have a “living will”?
 No  Yes
Do you have a donor card?
 No  Yes
Occupation:_________________________________
 No  Yes
 No  Yes
 No  Yes
Past Medical History & Review of Systems:
Please circle if you have had problems with or are presently complaining of any of the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
High Blood Pressure
Diabetes
Cancer
Heart Disease
Chest pain/chest tightness
Shortness of breath
Swollen ankles
Palpitations
Light-headedness
Frequent urination
Rheumatic fever
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23
24.
25.
Bronchitis
Pneumonia
Persistent cough
T.B. (tuberculosis)
Hay fever (allergies)
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
Change in bowel habits
Unexplained weight loss/gain
Hemorrhoids
Gall bladder disease
Colitis
Hepatitis or jaundice
Thyroid disease
Head or neck radiation
Headache
Kidney disease
Kidney stones
38
39.
40.
41.
42.
43.
44.
45.
46.
47.
49.
Arthritis
Low back problems
Skin disorders
Blood disorders
Venereal diseases
Abdominal discomfort
Anxiety
Indigestion
Depression
Nausea
Anemia
Vomiting
Alcohol abuse
Constipation
Drug abuse
Diarrhea
Last dental
Blood in stool
visit_________
12. Asthma
Ulcers
37. Difficulty urinating
50. Last Ophthalmologist
visit_____________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Please list and supply dates of:




Immunizations
Hepatitis B
Pneumovax
Flu
Tetanus
Surgeries
Other Hospitalizations
All of your medical records in this office are confidential. No one is allowed access to your information without written consent
from you. If you would like your information released to a parent or guardian, you must sign a release form giving us permission.
By signing this, I confirm that the statements completed by me today are to the best of my knowledge.
_______________________________
Name
_________________________________
Signature
__________________
Date
Patient Demo and History DUSHC – rev 9/2/2008