Rocky Mountain Center for Clinical Research
Name________________________________ Age________ Date of Birth_______________ Today’s Date____________
Address___________________________________________________________________________________________________
Phone: Home___________________________ Work____________________________ Cell____________________________
Primary Care Physician____________________________ Address and Phone_________________________________________
Any other specialists you see___________________________________________________________________________________
Emergency Contact Name and Phone Number ______________________________________________________________________
MEDICAL HISTORY (any medical conditions you have)_________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
SURGERIES AND HOSPITALIZATIONS (list all operations you have had or reason for hospitalization)
Surgery / Hospitalization
Date
Surgery / Hospitalization
ALLERGIES: Are you allergic to any medicines (including iodine, latex or anesthesia)? If yes, please complete:
Allergy
Type of Reaction
Date
Allergy
Type of Reaction
Date
Date
MEDICATIONS: List all medications, including inhalers, over the counter drugs, and supplements you have taken in the last 3 months:
How often
Medication/Indication
Are you on oxygen?
Dose per day
Yes
No
How often
Medication/Indication
Dose per day
How often
Medication/Indication
Dose
per day
If yes, how many liters/minute? ____________ How many hours/day? ____________
VACCINATIONS: Please circle and date all that apply: Pneumovax______________________ Flu______________________
TESTS/TREATMENTS/PROCEDURES: Have you ever had a chest x-ray? No
Yes Date ________________________
SOCIAL HISTORY
Occupation______________________________________
Any Toxic/Occupational Exposure?___________________
Marital Status M S D W # of children_______
Have you ever smoked? No Yes If you still smoke, how many years have you smoked_______How many packs per day________
If you’ve quit, how many years did you smoke____,
_______ packs/day
How many years ago did you quit______
Do you drink alcohol? No Yes If yes, #______per day
Recreational Drug use? No Yes ___________________
Pets?____________________________________________
Foreign travel in the past year?________________________
Subject Signature __________________________________
Staff Signature _____________________________________
PLEASE COMPLETE ADDITIONAL QUESTIONS ON THE REVERSE SIDE
Review of Systems / Medical History Have you been diagnosed with any of the following problems and/or are you currently
having any of the following symptoms?
Subject Name _______________________________________
Constitutional
Unintended weight loss
Unintended weight gain
Fever
Chills
Night sweats
Weakness
Subject Name __________________________________
Review of Systems / Medical History Have you been
diagnosed with any
of the following
problems, and/or are
you currently having
any of the following
symptoms?