Occupational Health Medical History Form

Date:
Interpreter: Yes No If yes, what language?
SECTION I. IDENTIFICATION
Occupational Health
Medical History Form
Time:
Name:_________________________________________________________________________________________
Social Security Number: ______________________Date of Birth: ______________Age: ________ Male Female
Primary Care Provider: ________________________________ Last complete physical: _______________
Up-to-date immunizations? Yes No Unknown
Date of last Tetanus: __________________
SECTION II. OCCUPATIONAL HISTORY
Position/Department:________________________________________________________Start Date:_______________
Employer:_____________________________________2 nd jobs/other part-time employment:______________________
Have you ever…..
1) Had a work-related injury that caused time off work? Yes No
2) Received/pending/applied for pension or compensation for existing disability? Yes No
3) Refused/unable to hold a job due to dust, chemicals, inability to do certain motions? Yes No
4) Refused or unable to hold a job due to other medical reasons? Yes No
If yes, please describe (Employer, Job Title/Duties, Injury/Illness, when):_______________________________________
__________________________________________________________________________________________________
SECTION III. CURRENT PROBLEM: Medical care sought for this injury/problem (if any):
Emergency Room/Urgent Care
Specialist:______________________________________________
Family Practice/Primary Care Provider Occupational Therapy/Physical Therapy Other: _____________
SECTION III. MEDICATIONS : NONE
List current medications: prescription,
nonprescription or herbs/supplements
1.
2.
3.
4.
5.
Frequency: (# per day or
occasionally)
Reason for medication/Diagnosis
Medication/environmental or other allergies:___________________________________________________________
_______________________________________________________________________________________ NONE
SECTION IV. SOCIAL HISTORY
Do you feel safe in your current relationships? Yes No
Have you ever used tobacco? Yes No If yes, what type? Cigarette Pipe/Cigar Snuff/Chew
Amount per day: __________________________ How many years?_________________
Use Tobacco Currently Quit ___________ years ago Interested in Quitting
Average alcohol intake in a week? _____________Type of drinks:___________________# of drinks/day: ________
Have you ever felt you should cut down or criticized by others for alcohol use? Yes No
Recreational drug use: Never What and when:________________________Treatment/Rehab: _______________
Average caffeine intake in a week?__________ Type of drinks:_____________________# of drinks/day:___________
Family status: Single Married Divorced Widowed # of Children (ages):___________________
Major life changes in the last year (ex: new baby, job change, marriage, death in family):_____________________
Regular exercise? No Yes (type, frequency?)_______________________________ Sleep: _______hours per night
Hobbies:_________________________________________________________________________________________
Highest level of education:__________________________ Learning style visual auditory tactile/ “hands-on”
Military History(branch & number of years): _________________________________________________________
Rejected from military due to physical/mental or other reason (date and reason)? _______________________________
Type of discharge Honorable Unfit/unsuitable for duty Other/specify:_________________________________
S:\COLLABORATIVES\Nursing Admin\Independent Contractors\IC Working File\Medical History Form November 2010 - 3 - 5.docx

SECTION V. FAMILY HISTORY:
Please indicate current status of immediate family (parent, sibling, child)
Alcohol/Drug abuse:___________ Depression/Suicide:____________ Asthma/COPD:_______________
Cancer(type):_________________ Genetic disorders:_____________ Diabetes:____________________
Heart disease:_________________ High blood pressure:___________ Stroke:_____________________
Bleeding disorder/clots:_________ Healthy:_____________________ Other:______________________
SECTION VI. MEDICAL HISTORY
Handedness: Right Left
Have you been diagnosed with any of the following conditions?
Alcohol/substance abuse Seizures Arthritis, Rheumatism or Bursitis Thyroid Problem
Cancer Liver disease Bone or Joint problems Back pain/injury
Diabetes Lung Disease Heart problems/High blood pressure Prostate Problems
Major Accident Kidney Disease Stomach/Intestine problems Migraines
Claustrophobia Asbestos/toxic chemical exposure Depression/Anxiety/Mental Health Conditions
Type and when: ____________________________________________________________________________________
Please list all other medical conditions: _________________________________________________________________
---------------------------------------------------------------------------------------------------------------------------------------------------
(Provider comments:________________________________________________________________________________)
SECTION VII. HOSPITALIZATION/SURGERIES (Advised to have/had a procedure or surgery? Yes No )
Year Reason Year Reason
SECTION VIII. REVIEW OF SYSTEMS (Which of the following are problems at this time?)
General/Constitutional
Heart/Lungs
Ears/Nose/Throat
Fever >100
Chest Pain or Pressure
Difficulty Hearing
Shivering/Chills
Irregular Heart Beat
Ringing, Buzzing
Generalized Weakness
Palpitations/Skipped Beats
Wear a Hearing Aid
Unexplained Weight Loss/Gain
New or Changed Cough
Sneezing/Runny Nose
Excessive Fatigue
Coughing Up Blood
Nosebleeds
Swollen Glands
Wheezing
Difficulty Swallowing
Loss of Consciousness/Head injury Shortness of Breath
Dry Mouth
Loss of Appetite
Night Sweats
Dizziness
Neurological/Psychiatric
Headaches
Numbness or Tingling
Depression/Excessive Anxiety
Insomnia/Difficulty Sleeping
Loss of Memory
Suicide Attempt or Plans
Musculoskeletal
Muscle Pain
Back Pain
Neck Pain
Weakness in Arms/Legs
Swollen or Painful Joints
S:\COLLABORATIVES\Nursing Admin\Independent Contractors\IC Working File\Medical History Form November 2010 - 3 - 5.docx
Eyes
Wear Corrective Lenses
Change in Vision
Lack of Vision in Either Eye
Itching
Tearing
Digestive System
Skin
Genitourinary and Reproductive
Nausea/Vomiting
Rash
Difficult or Painful Urination
Diarrhea
Moles-Changed in Size/Color Blood in Urine
Constipation
Itching
Fertility Problems
Rectal Bleeding or Black Stools Non-healing Wound or Ulcer
Teeth/Gum Disease
Women Only
Men Only
Specify: ______________________ Breast Lump/Discharge
Lump in Testicle
Currently or Possibly Pregnant Impotence
I certify I have answered these questions to the best of my knowledge and the answers are complete and true.
Patient Signature: __________________________________________________________ Date: ___________________
Provider Signature: _________________________________________________________Date: ___________________
Patient 2 nd Injury Review: ____________________________________________________Date: ___________________
Provider Signature 2 nd Injury: _________________________________________________Date: ___________________

S:\COLLABORATIVES\Nursing Admin\Independent Contractors\IC Working File\Medical History Form November 2010 - 3 - 5.docx