LESSON
3
Complete a medical history form
PRACTICAL SKILLS
GET READY
Biata is entering information from a patient’s medical history form into the database.
Guess: What type of information is on the form?
PRACTICAL READING
A
Read the patient’s medical history form. Was your guess correct?
MEDICAL HISTORY
Last Name First Name Date of Birth Gender Marital Status
______________________________________________________________________________
CHOI
JENNY
9/28/68 FEMALE MARRIED
Address
City, State
Zip Code
Telephone
______________________________________________________________________________
In Case of Emergency, Contact:
Telephone
_____________________________________________________
2108 BERRY ST. APT. 301
MIN CHOI
(281) 555-8121
HOUSTON, TX 77004 (281) 555-4982
Employer
Occupation
Social Security #
______________________________________________________________________________
Employer’s Address
Work Telephone
______________________________________________________________________________
Insurance Company
Policy #
______________________________________________________________________________
GENERAL HEALTH
1. Has there been any change in your health in the past year? YES NO
If yes, explain: _________________________________________________________________
2. Are you taking any medication now?
YES NO
If yes, what drugs or medication? _______________________________________________
3. Do you have allergic reactions to any drugs?
YES NO
If yes, which drugs? ___________________________________________________________
4. Have you ever been hospitalized, or had a serious illness? YES NO
If yes, explain: _________________________________________________________________
PERSONAL MEDICAL HISTORY
Have you ever had any of the following medical conditions?
Alcoholism
Cancer
Depression
Diabetes
Migraines
Tuberculosis
Osteoporosis
High blood pressure
Other (please list) _____________________________________
3815 KIRBY DR., HOUSTON, TX, 77098
(281) 555-2898
ASSURE HEALTH
10956338
HAIR TRENDS
HAIR STYLIST
000-28-7014
INSOMNIA, WEIGHT LOSS, BACK PAIN
IBUPROFEN PAIN RELIEVER
PENICILLIN
78
UNIT 6
