UC Davis Employee Health

UC Davis Occupational Health Services Medical History for New Patients

Name: ______SS#:______

DEPT ______Phone # ______DOB:______

Address______

Medical History  Last Tetanus Booster: Year ______ Hepatitis B Immunization: Year______Hepatitis B Titer? No Yes If yes what were results?______ Last TB Screen Test: Year ______Positive Negative Never tested History of active Tuberculosis

Are you currently taking medications? No Yes (If yes, list below) ______

Do you have any allergies to any medicines? No Yes (If yes, list below) ______

Have you had any other (non-allergic) reactions or other problems with medicines? No Yes (If yes, list below) ______

Have you had any surgeries? No Yes (If yes, list below) ______

Have you had any hospitalizations? No Yes (If yes, list below) ______

Cardiac or circulatory problems? No Yes (If yes, circle all that apply)  High Blood Pressure  Varicose Veins  Heart attack  Swelling of feet or legs  Heart murmur  Blood disorder or anemia  Irregular heart beat  Bleeding disorder  High cholesterol  Other ______

Lung or Respiratory problems? No Yes (If yes, circle all that apply)  Asthma  Bronchitis or Chronic cough  Pneumonia  Ever smoked cigarettes/other substances? What type______age started______age stopped_____  Other ______

Endocrine, “glandular”, or “hormone” problems? No Yes (If yes, circle all that apply)  Diabetes  Thyroid problem

Intestinal or abdominal problems? No Yes (If yes, circle all that apply)  Liver Problems  Hernia or "rupture"  Have you had any abdominal operations? No Yes (If yes, list below) ______ Ulcers or colitis  Other______

PLEASE TURN FORM OVER TO COMPLETE

Rev 04/11 D:\Docs\2017-12-28\02ff657b9f6def75d16be3f32afaa9e4.doc Dermatologic or skin problems? No Yes (If yes, circle all that apply)  Psoriasis  Eczema  Contact Dermatitis  Other chronic skin problems: ______

Eye problems? No Yes (If yes, circle all that apply)  Eye injury or infection  Wear glasses or contacts  Color blindness  Glaucoma

Ear and upper respiratory problems? No Yes (If yes, circle all that apply)  Hearing loss or perforated ear drum  Chronic or frequent colds  Allergies to dust, pollen, etc.  Other______

Nervous system problems? No Yes (If yes, circle all that apply)  Chronic headache  Stroke  Seizure  Fainting spells or loss of consciousness  Muscle weakness or paralysis  Other______

Orthopedic (bone muscle or joint) problems? No Yes (If yes, circle all that apply)  Fractures  Back pain, sciatica or herniated disc injury or surgery  Neck strain or whiplash or neck surgery  Knee injury (i.e. torn cartilage or torn ligament, kneecap problems)  Carpal tunnel syndrome  Wrist or forearm problems  Tennis elbow  Shoulder dislocation rotator cuff  Arthritis  Other______

Other medical problems? No Yes (If yes, circle all that apply)  Tumor (benign or cancer)  Kidney or bladder problems  Drug or alcohol problem  Have you been under a doctor's care for medical or emotional problems during the past 5 years? No Yes

Work history: Date last worked: ______ Medical discharge from military? No Yes  Have you had a work-loss injury? No Yes  Have you received compensation for an industrial injury? No Yes  Do you have a permanent disability rating from an industrial injury? No Yes

PATIENT SIGNATURE______DATE______

PLEASE TURN FORM OVER TO COMPLETE