Nursing/Teaching Exam Medical History form --- to be completed by student
Age: _____ Sex: M F
Allergies to medications: _____________________________
Current medications: ___________________________________________________________
Current medical illness being treated: _____________________________________________
Do you have any concerns about your ability to function in clinical nursing/teaching? Y N
Past hospitalizations (year/reason) _______________________________________________
Past treatment for illnesses (diabetes, thyroid, heart murmur, depression, eating disorder,
other______________________________________________________________________
Social History
Do you smoke cigarettes? Y N Packs per day:
Use other tobacco products? Y N
Do you drink alcohol? Y N Drinks/week average:
Do you use recreational drugs? Y N
Do you ever drink and drive or ride with people who drink and drive? Y N
Do you wear seat belts? Y N
Do you exercise? Y N
Number sessions/week:
Family History: Have immediate relatives (parents, brothers, sisters) had?
Y N Relationship
Y N Relationship Type
High Blood Pressure
Stroke
Heart Attack age <50
Diabetes
Cancer
Thyroid disease
Blood clotting disorder
Psychiatric illness
REVIEW OF SYSTEMS: Have you had during the last year: (CIRCLE any that apply)
General: unexplained weight changes, unusual fatigue, fever, chills, sweats at night
Skin: changes in existing moles, new moles, poorly healing wounds, rashes
Eyes/Ears: blurred vision, double vision, loss of hearing
Cardiac: chest pain, racing or irregular heart beat
Lungs: cough, wheezing, shortness of breath with activity
Gastrointestinal: diarrhea, constipation, change in bowel habits, blood in stool, dark black
stools, abdominal pain
Genitourinary: pain with urination, blood in urine, frequent bladder infections
abnormal vaginal bleeding or discharge
Last period _______________
Breasts: breast lump, nipple discharge, pain in breast
Musculoskeletal: unusual muscle or joint pain, anything that limits your activity
Neurologic: frequent headaches, fainting, blackouts, seizures, weakness, tingling, tremors
Psychiatric: depression, unusual anxiety, history of taking psychiatric medications (name of
meds with approximate dates taken)
Student signature _____________________________________Date _______________
5/04