University of Rochester
Subject Initials ______ ______ _______
First
Middle
Last
STUDY PROTOCOL #: __________________________ Subject Number: _________________
PATIENT MEDICAL HISTORY
NAME: ___________________________________________________________________________
First
Middle
Last
Address: ___________________________________________________________________________
City/Town: _____________________________________ Zip Code _________________
Telephone Number: Day _________________________ Evenings ___________________
Date of Birth _____/_____/_____
Day Month Year
Sex: M
Ethnic Origin: __________
__________
__________
__________
__________
Caucasian
Black
Hispanic
Asian
Other
F
Name of Family Physician: ____________________________________________________________
Address:_____________________________________________________________________________
_________________________________________________________________
Name of Other Doctor(s) (Specialists): __________________________________________________
__________________________________________________
This information is to be used by medical staff to screen for possible eligibility in a clinical research
study. Patients are told that giving false, incomplete or misleading information about their medical
history could have serious consequences to their health while participating in a clinical trial. All
information received in this document is kept completely confidential.
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University of Rochester
Subject Initials ______ ______ _______
First
Middle
Last
MEDICAL / SURGICAL HISTORY
Have you had any operations? If YES, please list below:
CONDITION
DATE (MM/YY)
NO
YES
CONTINUES?
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
PREVIOUS HOSPITALIZATIONS
NO
YES
If YES, list below any hospitalizations NOT listed in SURGICAL HISTORY
REASON
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DATE (MM/YY)
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University of Rochester
Subject Initials ______ ______ _______
First
CURRENT MEDICATIONS
Have you taken any medication in the last 30 days?
NO

Middle
Last
YES

List any and all medications you have taken (including any over-the-counter products (OTC),
Medication
Ex. Tylenol
OTC or
RX
OTC
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Dosage
325 mg.
Frequency
Twice/day
Date of
First Dose
02JAN2012
Date of
Last Dose
(Complete
only if
discontinued)
04JAN2012
Reason
Headache
15-Apr-13
University of Rochester
Subject Initials ______ ______ _______
First
Middle
Last
ALLERGIES AND SENSITIVITIES
Do you have any allergies or sensitivities?
NO
If YES, indicate below:
Type may include: Medication, Food, Environmental, etc.
Type of Allergy
Name of Allergen
YES
Date of Onset
Symptom/Reaction
FEMALES ONLY (for males check N/A )
Contraception
Forms of birth control you are currently using (check):
 Abstinence
 Diaphragm & Spermicide
 Condom
 Hysterectomy
 I.U.D.
 Condom & Spermicide
 Diaphragm
 Oral Contraceptive (pill)
 Norplant Date of Implant:__________________________
 Depo-Provera: Last injection date: ___________________
 Post menopausal for 2 years +
 Tubal Ligation
 Vasectomized Partner
 Other ____________________
Specify date if applicable: ____________________________________________
Are you currently nursing (breast-feeding)?
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NO YES
15-Apr-13
University of Rochester
Subject Initials ______ ______ _______
First
Middle
Last
SYSTEM REVIEW
Do you have or have you ever had any disorder of the EYES, EARS, NOSE OR THROAT?
Condition/Diagnosis
Date of Onset or Diagnosis
Do you have or have you ever had any CARDIOVASCULAR disorders?
Condition/Dianosis
Date of Onset or Diagnosis
Do you have or have you ever had any Respiratory disorders?
Condition/Diagnosis
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Date of Onset or Diagnosis
NO
YES
Active or Non-Active
NO
YES
Active or Non-Active
No
Active or Non-Active
15-Apr-13
Yes
University of Rochester
Subject Initials ______ ______ _______
First
Do you have or have you ever had any GASTROINTESTINAL disorders?
Condition/Diagnosis
Date of Onset or Diagnosis
Middle
Last
NO
YES
Active or Non-Active
Do you have or have you ever had any GENITOURINARY-REPRODUCTIVE disorders?
NO
YES
Condition/Diagnosis
Date of Onset or Diagnosis
Active or Non-Active
Do you have or have you ever had any MUSCULOSKELETAL disorders?
Condition /Diagnosis
Date of Onset or Diagnosis
NO
YES
Active or Non-Active
Do you have or have you ever had any NEUROLOGICAL-PSYCHIATRIC disorders?
NO
YES
Condition
Date of Onset or Diagnosis
Active or Non-Active
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15-Apr-13
University of Rochester
Subject Initials ______ ______ _______
First
Middle
Last
Do you have or have you ever had any HEPATIC-BILIARY disorders?
Condition
Date of Onset or Diagnosis
No
Yes
Active or Non-Active
Do you have or have you ever had any ENDOCRINE disorders?
Condition
Date of Onset or Diagnosis
No
Yes
Active or Non-Active
Do you have or have you ever had any CANCER occurrence?
Condition
Date of Onset or Diagnosis
NO
YES
Active or Non-Active
Do you have or have you ever had any HEMATOLOGIC, LYMPHATIC or IMMUNE disorders? NO YES
Condition
Date of Onset or Diagnosis
Active or Non-Active
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15-Apr-13
University of Rochester
Subject Initials ______ ______ _______
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Have you participated in a CLINICAL TRIAL in the last 30 days?
Yes or No
If YES, please specify, and give date(s)
___________________________________________________________________________
___________________________________________________________________________
Study Staff Reviewing Information collected: _________________________________
Date:_________________
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