Personal information is strictly for the use of
Student/University Health Services and will not be
released to anyone without your knowledge or consent.
ETSU
STUDENT/UNIVERSITY HEALTH SERVICES
Please Print Legibly in INK
Social Security Number
___ ___ ___-___ ___-___ ___ ___ ___
PO BOX 70675
Johnson City, TN 37614
Form will not be processed without this number
REPORT OF MEDICAL HISTORY
ETSU ID# E____________________ ___
PLEASE COMPLETE THIS FORM AND BRING WITH YOU FOR YOUR APPOINTMENT!
SEX: M
FIRST NAME
MIDDLE
LAST NAME
HOME ADDRESS (NUMBER AND STREET)
CITY
STATE
ZIP CODE
DATE OF BIRTH
NAME, RELATIONSHIP, AND ADDRESS OF EMERGENCY CONTACT (BUSINESS)
MARITAL STATUS: SINGLE
MARRIED
WIDOWED
OTHER
AGE
(HOME) PHONE NUMBER
DO YOU HAVE INSURANCE? YES
NO
Have any of your grandparents, parents or siblings ever
had any of the following diagnosed illnesses?
Immediate Family History:
STATE OF
HEALTH
F
AGE
OF
DEATH
OCCUPATION
CAUSE OF DEATH
YES
FATHER
TUBERCULOSIS
MOTHER
DIABETES
NO
RELATIONSHIP
KIDNEY DISEASE
BROTHERS
HEART DISEASE
ARTHRITIS
STOMACH DISEASE
ASTHMA
SISTERS
MIGRAINE
EPILEPSY,
CONVULSIONS
CANCER
(what type)
THYROID
DISEASE
PERSONAL HISTORY Please answer all Questions. Comment on all positive answers in space provided or on back of this sheet.
YES
ALLERGIES TO MEDICATIONS
(DESCRIBE ALL REACTIONS)
NO
COMMENTS:
Additional medication allergies and description of allergic response:
PENICILLIN
SULFONAMIDES
SERUM
OTHER
ALLERGIES TO FOODS
A. Has your physical activity been restricted during
the last five years due to a chronic condition? (Give
reason and durations)
B. Have you been exposed to violence in the home,
school or community?
C. Have you received treatment or counseling for a
nervous condition, personality or character disorder,
or emotional problem?
D. Have you had any chronic illnesses or injuries or
been hospitalized other than already noted? (Give
Details)
E. Have you consulted or been treated by clinics,
physicians, healers, or other practitioners within the
past five years? (Other than for routine checkups)
List food allergies
PERSONAL HISTORY, CONTINUED
YES
NO
COMMENTS:
F. Have you been rejected for or discharged from
military service because of physical, emotional, or
other reasons? If yes, give reasons.
G. List Date of last pap, Date of Last Vision Exam,
Date of Last Dental Exam.
PERSONAL HISTORY: Have you been diagnosed with any of the following illnesses?
HAVE YOU HAD?
YES
NO
YES
NO
YES
NO
YES
Rheumatic Fever
Worry or
Nervousness
Heart Murmur
Dizziness, Fainting
Scarlet Fever
Frequent Anxiety
High/Low Blood Pressure
Weakness, Paralysis
Chicken Pox
Frequent Depression
Palpitations (heart)
MALES ONLY:
Measles
Insomnia
Disease/Injury of Joints
Testicular Pain /Swelling
Mumps
Recurrent Headache
Arthritis
Penile Discharge
German Measles
Recurrent Colds
Ear, Nose, Throat Trouble
Genital Warts
Malaria
Head Injury with
Unconsciousness
Back Problems
Painful Urination
Gum or Tooth
Trouble
Hay Fever/Asthma
Tumor, Cyst
FEMALES ONLY:
Sinusitis
Tuberculosis
Stomach /Intestinal Trouble
Abnormal Pap
Eye Trouble
Shortness of Breath
Cancer
Irregular Periods
Epilepsy,
Convulsions
Chronic Cough
Jaundice
Severe Cramps
Surgery:
Rupture Hernia
Sexually Transmitted Diseases
Excessive Flow
Appendectomy
Migraine Headaches
Urinary Tract Infections or
kidney problems/disease
Vaginal Infections
Tonsillectomy
Diabetes
Gallbladder Trouble or
Gallstones
Genital Warts
Hernia Repair
Low Blood Sugar
Recurrent Diarrhea
Ovarian Cysts or Tumors
Other Surgery
Known heart
problems
Recent Gain or Loss of Weight
Other
Vein Problems,
Blood Clots
Pain/Pressure in
Chest
“Trick” knee, Shoulder, etc.”
Other
Comments:
Patient’s Signature:
Date:
Reviewed by:
Date:
NO