PERSONAL HEALTH AND MEDICAL FORM

COMPLETE IN ENGLISH BLOCK CAPITALS ONLYNAME _____________________________________________

DATE OF BIRTH ________________ GENDER. M

Current Concerns
1.____________________________________________________
2.____________________________________________________
3.____________________________________________________

Contact person next of kin___________________________________________ Other Healthcare Practitioners

___________________________________________ 1.____________________________________________________
Past Medical Diagnoses, surgeries, hospitalizations

2.____________________________________________________
Date of last: Physical exam
_________

1.________________________________________________

Lab tests

_________

2.________________________________________________

Dental visit

_________

3.________________________________________________

Last tetanus shot

_________

OTHER MEDICAL HISTORY AND REVIEW OF SYSTEMS

GENERAL

Hemorrhoids
Blood in stool
Leaking stool
Black stools

MIND

Fatigue
Weight change
Difficulty losing

Hearing loss
Ringing in ears
Post nasal drip
Sinus congestion

Fever
Night sweats
Headache
Eating disorder

Hay fever
Bloody nose
Cold sores
Canker sores

Abdominal pain
Change in stool
Gall stones
Hernia

Addiction
Slow healing
Fainting/ dizziness
Insomnia

Bleeding gums
Sore throat
Bad breath

Low blood sugar

Anxiety
Panic attacks
Forgetful
Poor
concentration
Bad dreams
Bipolar disorder
Negative thoughts
- persistent

Difficulty coping
Excessive stress
Depressed

ENDOCRINE
Diabetes
Thyroid disorder
Too hot or cold

wt

SKIN
Rash
Itching
Dryness
Color changes
Moles
Excessive sweat
Hair loss
Heavy body hair
Ridges in nails
White spot on
nails

Difficult to swallow

LUNGS
Cough
Wheezing
Short of breath
Asthma
Bronchitis
Painful breathing
HEART
Heart murmur
Palpitations

URINARY
Painful urination
Weak urine stream
Blood in urine
Kidney infections
Nighttime urination
Leaking urine
Bladder infection

MEN ONLY

Nipple discharge
PMS (women)
Always thirsty

SEXUALITY
Low libido
History STD
Pain during sex
Difficult to orgasm
Sexual abuse

Penile discharge
Erectile dysfunction

Prostate problems
Testicular pain
Lump on testicle

OTHER
Hospitalized
Surgery
Blood transfusion

MUSCULOSKELETAL

Joint pain
Joint deformity
Muscle tension
Back pain

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WOMEN ONLY
GYN HISTORY
Age at first period? _______________________
How often do you have a period? ____________

PERSONAL HEALTH AND MEDICAL FORM

Who do you turn to for support? ________________________

Who lives in your home? ______________________________
What causes stress for you?
What is your occupation? _____________________________

NO Have you ever had an operation in last year?

YES

NO have you ever suffered internal injuries?

YES

NO do you have malaria?

NO Have you ever been pregnant?

Date of Births:
1.
2.
3.

Habits:
Alcohol
Tobacco
Recreational Drugs
Caffeine
Exercise
Toxic exposures through work or
hobbies

____________________________

YES

YES

# Abortions: ___ miscarriages? ____ adoptions ____

Rarely or NO

Heartburn/ reflux
Vomit blood
Stomach pain
Constipation
Diarrhea

PREGNANCY HISTORY

Monthly

GASTROINTESTINAL

Numbness
Tingling
Weakness
Loss of balance
Loss of smell/ taste
Seizure
Shooting pains

Weekly

Eye pain
Eye discharge
Vision changes
Glasses/ contacts
Double vision
Glaucoma
Cataract
Ear infections

How many days do you bleed? ______________

Have you ever had a breast lump? ____________

NEUROLOGICAL

Daily

Chest pain
Swelling
Anemia

EENT

FAMILY HISTORY

MEDICATIONS

High blood pressure _______________________________

Tuberculosis _____________________________________
Heart
disease
_____________________________________
Thyroid
disorder
__________________________________

Current Prescription Medications

1.____________________________________________________

Diabetes_________________________________________
Stroke __________________________________________
Kidney
Disease
___________________________________
Arthritis
_________________________________________
Allergy
__________________________________________
Cancer
__________________________________________
Obesity _________________________________________

2.____________________________________________________

2.____________________________________________________
3.____________________________________________________
Current Over the Counter Medications
1.____________________________________________________
Current vitamins, herbs, homeopathics
1.____________________________________________________
2.____________________________________________________
3.____________________________________________________
Have you had a tetanus booster in the last 10 years?
NO

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YES

PERSONAL HEALTH AND MEDICAL FORM

Autoimmune
_______________________________

disease
Epilepsy

_________________________________________
Substance
__________________________________

Abuse

Osteoporosis______________________________________
Other
___________________________________________

ALLERGIES:
Drug
____________________________________________
Environmental ____________________________________
Food____________________________________________

Reviewed by __________________________________

Date __________________

Other information by employee.-

PLEASE NOTE THIS FORM IS CONFIDENTIAL AND SHALL NOT BE DISCLOSED TO

UNAUTHORISED PERSONNEL. IT SHALL ACCOMPANY THE PATIENT TO A TREATING
PHYSICIAN IF THE NEED ARRISES. A COPY SHALL BE KEPT WITH HR AT SITE AND THE
CAMP BOSS IN THE CAMPS.

Confide
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