MEDICAL HISTORY AND ADMISSION EXAMINATION
(To be submitted by examining physician or completed within 72 hours after arrival)
Last Name
First Name
Attending Physician
Room No
Patient No
Examining Physician ___________________________________________________ Phone ________________________________
Address ____________________________________________________________________________________________________
PERTINENT MEDICAL HISTORY
Diabetes ____________________________ Epilepsy ____________________________ Arthritis ____________________________
Kidney: Last Diagnosis ____________________________________________________ Date _______________________________
CVA: Last Diagnosis ______________________________________________________ Date _______________________________
Tuberculosis: Last Diagnosis ________________________________________________ Date _______________________________
Other Lung Condition: Last Diagnosis ________________________________________ Date _______________________________
Heart: Last Diagnosis _____________________________________________________ Date ________________________________
Cancer: Last Diagnosis ____________________________________________________ Date ________________________________
Mental Illness : Yes _____ No _____ Periods of Hospitalization ________________________________________________________
Most Recent Hospitalization for Mental Illness (Hospital) _____________________________________________________________
Address _________________________________________________ City _______________________ State ___________________
Other Diseases (Specify) _______________________________________________________________________________________
____________________________________________________________________________________________________________
Allergies ____________________________________________________________________________________________________
Permanent Disabilities _________________________________________________________________________________________
Operations __________________________________________________________________________________________________
Habits: Coffee ______________ Tea ______________ Smoking ______________ Alcohol _____________ Narcotics ____________
Dietary History _______________________________________________________________________________________________
____________________________________________________________________________________________________________
Sensitivities to Drugs and Allergies _______________________________________________________________________________
Continence: Continent ________________________________ Incontinent, feces only _____________________________________
Incontinent, urine only ________________________________ Incontinent, both feces and urine _____________________________
Current Medications, indication whether physician or self prescribed ____________________________________________________
____________________________________________________________________________________________________________
Chief Complaints (current) _____________________________________________________________________________________
____________________________________________________________________________________________________________
Most Recent Attending Physician __________________________________________ Phone ________________________________
Address ____________________________________________________________________________________________________
ADMISSION EXAMINATION
Height __________ Weight __________ Blood Pressure __________ Temp __________ Pulse __________ Respiration __________
Physical Condition: Good __________________________ Fair _________________________ Poor __________________________
Mental Condition: Clear ______________________ Partly Confused ___________________ Badly Confused ___________________
Ambulation: Self _____________________ With Assistance ____________________ Not Ambulatory ________________________
Eyes, Ears, & Teeth ___________________________________________________________________________________________
____________________________________________________________________________________________________________
X-Ray, Biopsy, Lab Analyses, Etc. _______________________________________________________________________________
____________________________________________________________________________________________________________
Behavior Problems ____________________________________________________________________________________________
____________________________________________________________________________________________________________
Does patient have a communicable disease? If so, explain _____________________________________________________________
Explain any other special problems, such as emotional disorders, speech, paralysis, arteriosclerosis, or arthritic condition __________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Functional limitations or special needs, such as patient has glasses, dentures, or prosthesis, requires help getting in and out of bed, etc.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Admission Diagnosis (state fully) ________________________________________________________________________________
____________________________________________________________________________________________________________
Admitting Orders: ____________________________________________________________________________________________
____________________________________________________________________________________________________________
Examining Physician (signature) __________________________________________________ Date __________________________