LESSON
PRACTICAL SKILLS
Read a medical history form
7
GET READY
Emily’s friend Eva has an appointment with her doctor. Before she sees the doctor,
she fills out a medical history form. Have you ever filled out a medical history form?
PRACTICAL READING
A
Read Eva’s completed medical history form. What is the purpose of
a medical history form?
YES NO
1. Is there a history of heart problems in your family?
2. Have you ever been hospitalized, had major operations, or had a serious illness?
If yes, explain. ____________________________________________________
3. Are you taking any drugs or medications now?
If yes, what? _____________________________________________________
4. Are you allergic to any medications?
If yes, what? _____________________________________________________
5. Are you on a special diet?
If yes, describe your diet. ____________________________________________
6. For women: Are you pregnant?
UNIVERSITY MEDICAL CENTER—PATIENT MEDICAL HISTORY
Name: _____________________ Birth date: ____________ Date of visit: ____________
Address: ____________________________________________ Phone #: _______________
Employer: ______________________________ Social Security #: ___________________
Medical insurance company: ____________________________ Policy #: ____________
What is the reason for your visit today? _______________________________________
_____________________________________________________________________________
Check any of the following conditions that apply to you:
Heart disease
Irregular heart beat
Diabetes
Asthma
Kidney disease
Thyroid disease
Stroke
Cancer or tumors
Lung disease / Tuberculosis
Arthritis
Liver disease / Hepatitis
High or low blood pressure
Smoking
Recent change in weight Allergies
Explain here any conditions you checked. ________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Patient Signature: ____________________________________ Date: ___________________
Eva Ortiz
1500 Sherman Drive, Long Beach, CA 90805
Sundale University
Health Now Group Medical
I had thyroid problems as a child.
Lisinopril for my high blood pressure
March 9, 2014
Eva Ortiz
I would like to learn about safe and
healthy ways to lose weight.
00-987-4343
555-12-1234
714-555-5555
3/26/70
March 9, 2014
I’ve had high blood pressure and have
been taking medication for 3 months. I’ve gained about 20 pounds over the last
year. I smoked from the age of 20 until 1 year ago.
70
UNIT 5
