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Medical History Form - Excel

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Medical History Form - Excel Powered By Docstoc
					MEDICAL HISTORY FORM
FULL NAME: DO YOU: Smoke? Drink Alcohol? Drink Coke? Drink Coffee? BIRTHDAY:

Yes Yes Yes Yes

Packs per day: Drinks per day: Liters per day: Cups per day:

LIST THE MEDICATIONS YOU ARE NOW TAKING:

LIST ANY ALLERGIES YOU HAVE TO DRUGS, FOOD OR OTHER ITEMS:

ARE YOU CURRENTLY UNDER MEDICAL CARE FOR ANY REASONS? Yes Please explain: WOMEN ONLY: Age when menstrual periods began: Are your periods regular? How many days do your periods last? How many times have you been pregnant? How many children born alive? PRIMARY CARE PHYSICIAN: Name: Address and City: Phone: PAST PSYCHIATRIC/MENTAL HEALTH CARE: Therapist’s Name: For How Long and When: LIST ALL OPERATIONS: Operation Performed

No

Year

Hospital

LIST ALL TIMES YOU HAVE BEEN ADMITTED TO A HOSPITAL OVERNIGHT (EXCEPT FOR CHILDBIRTH): Reason Hospitalized Year Hospital

DOES ANY RELATIVE (PARENTS, SIBLINGS, GRANDPARENTS, CHILDREN) HAVE HAD ANY OF THE CONDITION High blood pressure: No Kidney Disease: Stroke: No Bleeding Tendencies: Cancer: No Seizures: Emphysema: No Heart Disease: Ulcers: No Sugar Diabetes: Mental Illness: No Other Serious Illness: HAVE YOU HAD ANY OF THE FOLLOWING ILLNESSES? Measles: No Rubella (German Measles): No Chickenpox: No Mumps: No Whooping Cough: No Scarlet Fever: No Tonsillitis: No Diphtheria: No Asthma: No Glaucoma: No Cancer: No Angina Pectoris: No Ulcer: No Bladder or Kidney Infection: No Other Serious Illness:

Diabetes: Goiter, Thyroid Disease: Hives: Allergies: Eczema: Mono: Rheumatic Fever: Poliomyelitis: Pleurisy: Bronchitis: Influenza: Tuberculosis: Phlebitis:

PLEASE LIST THE DATE AND RESULT (IF KNOWN) OF YOUR LAST, X-ray: EKG: Blood Count: Date of last examination by a doctor:

ORY FORM
Date: 10/16/2009 No Yes

# Years smoked:

How Often?

Doctor

T FOR CHILDBIRTH): Doctor

AD ANY OF THE CONDITIONS LISTED BELOW: No Asthma: No Tuberculosis: No Colitis: No Anemia: No Gout:

No No No No No

No No No No No No No No No No No No No

Typhoid: Malaria: Tropical Diseases: Hepatitis: Venereal Disease: Seizures: Meningitis: Ear Infections: Heart Murmur: High Blood Pressure: Low Blood Pressure: Heart Attack: Kidney Stones:

No No No No No No No No No No No No No

Follow the steps to enable your Medical History Form.
>> 2) Your Medical History Form is ready to use. Following steps are for online use. Visit the site below: http://www.spreadsheetweb.com/getting_started.htm You will only need the username and password to create your Medical History Form. 3) Visit the site below: https://www4.spreadsheetweb.com/SpreadsheetWEB// Login to page with your new account information. 4) Click "Add Web Application" to upload this file. Your Medical History Form will be created automatically. You can simply use the Medical History Form from that link or place it on your website. Online forms will contain a "Save" button. Each time a form is filled and saved, the form will be saved on the "Data" tab. Hence, you can create a collection of Medical History forms saved by the names. >> >> Your Medical History Form will look like: http://www1.spreadsheetweb.com/SpreadSheetWeb/Output.aspx?ApplicationId=24d9e2e4-128a-4757-be92-e96be55967e4 In order to see more online applications created with PSW you can check the link below: http://www.spreadsheetweb.com/demos.htm

Copyright (c) 2009 Pagos, Inc. http://www.pagos.com/

saved on the "Data" tab.

28a-4757-be92-e96be55967e4


				
DOCUMENT INFO
Description: This is a sample medical history form that contains the necessary medical information of people. SpreadsheetWEB version of the calculator provides all features of the template and it may be placed and used online. A collection of Medical History Forms of people may be saved by the names of people.