PERSONAL HISTORY FORM
NAME:
AGE:
DATE:
/
/
ADDRESS:
OCCUPATION:
BIRTH PLACE:
DATE OF LAST PHYSICAL EXAM:
/
/
BIRTH DATE:
/
/
DOCTOR:
Please answer each of the following questions by placing an (X) between the “yes” brackets, if your answer to the
question is yes, or by placing an (X) between the “no” brackets, if your answer to the question is no. Fill in the “who”
(which blood relative e.g. father, mother, etc.) and “when” (approximate month, year) information when appropriate.
*Please note: Your employer will not be given any of this confidential information listed in these 4 pages.
FAMILY HISTORY:
Has any blood relative ever had?
Cancer, Leukemia
Tuberculosis
Diabetes
Heart Trouble
Heart Disease
Hign Blood Pressure
Stroke
Epilepsy
Bleeding Disorder
Asthma
Emphysema
Allergies
Liver Disease
Migraine
Headaches
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] Yes
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] No
Who
Who
Who
Who
Who
Who
Who
Who
Who
Who
Who
Who
Who
[
] Yes
[
] No Who
Alcoholism
Stomach or
Duodenal Ulcer
Kidney Disease
Glaucoma
Sickel Cell Anemia
Other Anemia
Mental Illness
Nervous
Breakdown
Suicide
Drug Abuse
Other Serious
Disease
RELATIVE
LIVING
? (Y/N)
DECEASED ?
(Y/N)
AGE
AGE
AT
DEATH
[
] Yes
[
] No
Who
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] Yes
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Who
Who
Who
Who
Who
Who
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] Yes
] Yes
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] No
] No
] No
Who
Who
Who
[
] Yes
[
] No
Who
CAUSE OF DEATH/COMMENTS
FATHER
MOTHER
BROTHER/
SISTER
HUSBAND
OR WIFE
SON OR
DAUGHTER
PERSONAL HISTORY:
Do you smoke?
[
] Yes
[
] No
[
[
] Yes
] Yes
[
[
] No
] No
Other alcoholic beverages?
[
] Yes
[
] No
How much of each (per week)?
Are you on a special diet?
[
] Yes
[
] No
What diet?
Do you drink?
Beer
Wine
If yes, What?
Page 1 of 4
X-RAYS:
Have you had any of these X-Rays? If yes, when?
Chest
Stomach
Colon
Gall Bladder
Back
Kidney
Extremities
Other
X-Ray
Treatments
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] Yes
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] Yes
] Yes
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When
When
When
When
When
When
When
When
[
] Yes
[
] No When
ALLERGIES:
Name any drugs, food, cosmetics or other substances to which you may
Have ever had an allergic reaction:
DEVICES:
Do you use:
IMMUNIZATIONS:
Have you received the following vaccines?
Hepatitis B
[ ] Yes
[ ] No Last Shot
Tetanus
[ ] Yes
[ ] No Last Shot
Flu
[ ] Yes
[ ] No Last Shot
Pneumovaccine [ ] Yes
[ ] No Last Shot
Hearing Aid
Neck Brace
Back Brace
Truss
Pacemaker
I.U.D.
Passary
Other device
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] Yes
] Yes
] Yes
] Yes
] Yes
] Yes
] Yes
] Yes
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] No
] No
] No
] No
] No
] No
] No
MEDICINES
Please list ALL medications that you are taking, including vitamins, birth control, and prescription drugs:
OPERATIONS/HOSPITALIZATIONS:
Please list ALL hospitalizations, beginning with the most recent (excluding routine childbirth):
REASON FOR
HOSPITALIZATION
HOSPITAL / CITY
DATE
COMMENTS
DIAGNOSED DIFFICULTIES:
Do you know, or have you in the past, had any of the following:
Migraine Headaches
Epilepsy or Convulsions
Stroke
Glaucoma
Cataracts
Blindness either eye
Ear Infections
Deafness
Asthma
Hay Fever
Chronic Bronchitis
Emphysema
Tuberculosis
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] Yes
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] Yes
] Yes
] Yes
] Yes
] Yes
] Yes
] Yes
] Yes
] Yes
Abnormal Chest X-Ray
Heart Murmur (as an adult)
Abnormal Electrocardiogram
Enlarged Heart
Heart Attack
Rheumatic Fever
Angina
High Blood Pressure
Gall Stones
Hepatitis
Cirhossis of the Liver
Stomach or Duodenal Ulcers
Abnormal Stomach X-Ray
Colon or Bowel Trouble
Page 2 of 4
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] Yes
] Yes
] Yes
] Yes
Rectal Trouble
Hemorrhoids or Piles
Dysentery / Serious Diarrhea
Kidney or Bladder Infections
Kidney Stones
Other Kidney Disease
Anemia
Poor Blood Clotting
Diabetes
On Insulin
Gout
Overactive Thyroid
Underactive Thyroid
Goiter
Broken Bones
Varicose Veins
Arthritis
Polio
Phlebitis
Syphillis or V.D.
H.I.V.
Gonorrhea
Skin cancer
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] Yes
] Yes
] Yes
] Yes
] Yes
] Yes
] Yes
Other Skin Disease
Serious Depression
Serious Emotional Problem
WOMEN:
Menstral Difficulties
Ovarian Cyst
Other GYN problems
Age Period Started
Still Menstruating
Cystitis
Other Illnesses
Number of Times Pregnant
Number of Children
Number of Miscarriages
MEN:
Prostate Trouble
Other Illnesses
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] No
] No
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] Yes
] Yes
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] Yes
] Yes
Do you have any of the following complaints:
General:
Fever
Chills
Aches or Pains
Unusual Weakness
Memory Loss
Swollen Glands
Easy Bruising
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Head:
Blurred Vision
not corrected
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Double Vision
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Light Flashes
[
Halos around
Lights
[
Pain in Eyes
[
Ear Pain
[
Drainage from Ear [
Hearing Difficulty
Or Deafness
[
Buzzing or Ringing
In Ears
[
Nosebleeds not
Due to Injury
[
Sinus Trouble
[
Difficulty
Swallowing
[
Mouth, Tooth, Tongue
Problems
[
Hoarseness
[
Severe Headaches [
Skin:
Changing Mole
Rash
Yellow Skin
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Yes
Yes
Yes
Yes
Yes
Yes
Yes
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] Yes
] Yes
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Yes
Yes
Yes
Yes
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] Yes
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] Yes
] No
] No
] No
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] Yes
] Yes
] No
] No
] No
[
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] Yes
] Yes
] Yes
Neck:
Swelling
Lumps
Stiffness
[
[
[
Chest, Heart, Lungs:
Shortness of
Breath
Poor Exercise
Tolerance
Fluttering of Heart
Unusual Heartbeat
Chest Pain or
Pressure Attacks
Frequent Cough
Coughing Blood
Wheezing
Night Sweats
Swollen Ankles
Leg Cramps
Gastrointestinal:
Poor Appetite
Weight Loss
Without Diet
Indigestion
Heartburn
Difficulty
Swallowing
Nausea / Vomiting
Vomiting Blood
Abdominal Pain
Or Cramps
Abdominal
Swelling
Diarrhea
Constiapion
] No
] No
] No
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] Yes
] Yes
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] No
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Yes
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] Yes
] Yes
Page 3 of 4
Change in
Bowel Habits
Pass Blood
from Rectum
Black, Tar-like
Bowel Movement
Kidney:
Blood in Urine
Pain or Burning
while Urinating
Difficulty
Passing Urine
Difficulty
Controlling Urine
Getting Up at Night
to Urinate
Genitalia / Women:
Breast Lump
Discharge / Nipple
Breast Problem
Vaginal Discharge
Vaginal Bleeding
or Spotting
Hot Flashes
Pain with
Intercourse
Possibly Pregnant
Change in Periods
Pain not Associated
with Periods
[
] No
[
] Yes
[
] No
[
] Yes
[
] No
[
] Yes
[
] No
[
] Yes
[
] No
[
] Yes
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] No
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] No
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] Yes
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] Yes
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No
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Yes
Yes
Yes
Yes
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No
No
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No
No
No
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Yes
Yes
Yes
Yes
Yes
Yes
[
] No
[
] Yes
Genitalia / Men:
Breast Lump
Discharge / Penis
Sore on Penis
Lump in Testicles
Difficulty having
Erections
Neuromuscular:
Weakness in
Arm or Leg
Difficulty with
Balance
Dizzy Spells
Fainting Spells
Speech Difficulty
Bones – Joints:
Painful Joints
Swollen Joints
Loss in Muscle
Strength
Lump or Swelling
In Muscle
Lump on Bone
Back Pain
[
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No
No
No
No
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Yes
Yes
Yes
Yes
[
] No
[
] Yes
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] Yes
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No
No
No
No
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] No
[
[
] Yes
] Yes
[
] No
[
] Yes
[
[
[
] No
] No
] No
[
[
[
] Yes
] Yes
] Yes
Yes
Yes
Yes
Yes
Endocrine:
Thirsty all the time
Cold most of the time
Too Warm most
of the Time
Unusually Tired
Unusually Jumpy
Or Nervous
Psychologic:
Do you find your life:
Unsatisfactory
Too Demanding
Boring
Satisfactory
[
[
] No
] No
[
[
] Yes
] Yes
[
[
] No
] No
[
[
] Yes
] Yes
[
] No
[
] Yes
[
[
[
[
Have you:
Seriously considered
Suicide
[
Attempted Suicide
[
]
]
]
]
No
No
No
No
] No
] No
[
[
[
[
[
[
]
]
]
]
Yes
Yes
Yes
Yes
] Yes
] Yes
General:
Have you had prolonged exposure to:
Loud Noise
[ ] No
[ ]
Spray Powders
[ ] No
[ ]
Insect Repellants
[ ] No
[ ]
X-Ray or Radiation [ ] No
[ ]
Dusty Conditions
[ ] No
[ ]
Have you ever had the following:
Minor Back Sprain [ ] No
[
Severe Back
Sprain
[ ] No
[
Lower Back Pain
[ ] No
[
Have you ever been rejected
by the Military
[ ] No
Have you ever had a claim for
Industrial Accident [ ] No
Occupational
Disease
[ ] No
Date
Date
Page 4 of 4
] Yes
] Yes
] Yes
[
] Yes
[
] Yes
I hereby declare that all of the statements and answers contained herein are complete and true.
Signature of Examining Physician
] Yes
[
BE SURE THAT YOU HAVE READ THE ANSWERS TO ALL QUESTIONS IN THIS MEDICAL
HISTORY BEFORE SIGNING
Signature of Member
Yes
Yes
Yes
Yes
Yes