MEDICAL HISTORY FORM

FULL NAME: BIRTHDAY:

DO YOU:
Smoke? Yes Packs per day:
Drink Alcohol? Yes Drinks per day:
Drink Coke? Yes Liters per day:
Drink Coffee? Yes 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? No
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 Year Hospital
LIST ALL TIMES YOU HAVE BEEN ADMITTED TO A HOSPITAL OVERNIGHT (EXCEPT FOR C
Reason Hospitalized Year Hospital

DOES ANY RELATIVE (PARENTS, SIBLINGS, GRANDPARENTS, CHILDREN) HAVE HAD AN

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 Diabetes:
Rubella (German Measles): No Goiter, Thyroid Disease:
Chickenpox: No Hives:
Mumps: No Allergies:
Whooping Cough: No Eczema:
Scarlet Fever: No Mono:
Tonsillitis: No Rheumatic Fever:
Diphtheria: No Poliomyelitis:
Asthma: No Pleurisy:
Glaucoma: No Bronchitis:
Cancer: No Influenza:
Angina Pectoris: No Tuberculosis:
Ulcer: No Phlebitis:
Bladder or Kidney Infection: No
Other Serious Illness:

PLEASE LIST THE DATE AND RESULT (IF KNOWN) OF YOUR LAST,
X-ray:
EKG:
Blood Count:
Date of last examination by a doctor:
TORY FORM
Date: 10/16/2009
No
Yes

# Years smoked:

EMS:

S?

How Often?

Doctor
RNIGHT (EXCEPT FOR CHILDBIRTH):
Doctor

ILDREN) HAVE HAD ANY OF THE CONDITIONS LISTED BELOW:

No Asthma: No
No Tuberculosis: No
No Colitis: No
No Anemia: No
No Gout: No

No Typhoid: No
No Malaria: No
No Tropical Diseases: No
No Hepatitis: No
No Venereal Disease: No
No Seizures: No
No Meningitis: No
No Ear Infections: No
No Heart Murmur: No
No High Blood Pressure: No
No Low Blood Pressure: No
No Heart Attack: No
No Kidney Stones: No

,
%3c%3fxml+version%3d%221.0%22+encoding%3d%22utf-16%22%3f%3e%0d%0a%3cWizardSettin
fMergedSavingCell%3e%0d%0a++++++++%3cMergedSavingCell%3e%0d%0a+++++++
MergedSavingCell%3e%0d%0a++++++++++%3cName%3ePSWMergedSaving
%3cListItemsAddress+%2f%3e%0d%0a++++++++++++%3cType%
ern+%2f%3e%0d%0a++++++++++++%3cAllowRounding
ndex%3e%0d%0a++++++++++++%3cIsHidingE
++%3cType%3e1%3c%2fType%3e%0d%
alueType%3eText%3c%2fValu
3c%2fWidth%3e%0d

UEsFBgAAAAAAAAAAAAAAAAAAAAAAAA%3d%3d
%3c%2fFontSize%3e%0d%0a++++++++++++++++%3cX%3e21%3c%2fX%3e%0d%0a++++++
.75%3c%2fWidth%3e%0d%0a++++++++++++++++%3cText+%2f%3e%0d%0a++++
%0a++++++++++++++++%3cMerge%3eFalse%3c%2fMerge%3e%0d%0a++
se%3c%2fWrapText%3e%0d%0a++++++++++++++++%3cFontSiz
a++++++++++++++++++%3cAddress%3e%3d'Readme
3cColSpan%3e2%3c%2fColSpan%3e%0d%0a+++
+++++++%3cFontName%3eCalibri%3c
cRowSpan+%2f%3e%0d%0a+
fInputCell%3e%0d%
0a++++++++++++++++%3cExport+%2f%3e%0d%0a++++++++++++++%3c%2fTD%3e%0d
++++++++++++++++%3cCellHasFormula%3eFalse%3c%2fCellHasFormula%3e%0d%0
++++++++++++%3cWrapText%3eFalse%3c%2fWrapText%3e%0d%0a++++
e%3eCalibri%3c%2fFontName%3e%0d%0a++++++++++++++++%
3c%2fFontName%3e%0d%0a++++++++++++++++%3c
se%3c%2fMerge%3e%0d%0a+++++++++++++
ize%3e%0d%0a+++++++++++++++
Align%3e%0d%0a++++++++
+++++++++++++
+++++%3cGrid+%2f%3e%0d%0a++++++++++++++++%3cExport+%2f%3e%0d%0a++++++
a++++++++++++++%3c%2fTD%3e%0d%0a++++++++++++++%3cTD%3e%0d%0
ormated%3e%0d%0a++++++++++++++++%3cStyle%3eClass8%3c%2fStyle
4.75%3c%2fWidth%3e%0d%0a++++++++++++++++%3cText+%2
me%3eCalibri%3c%2fFontName%3e%0d%0a++++++++++
mula%3e%0d%0a++++++++++++++++%3cFo
erge%3eFalse%3c%2fMerge%3e%0d%0
ght%3e%0d%0a+++++++++
0d%0a+++++++++
e%0d%0a++++++++++++++++++%3cRequiresValidation%3efalse%3c%2fRequiresValidation%
erticalAlign%3eCenter%3c%2fVerticalAlign%3e%0d%0a++++++++++++++++%3cCell
ext%3e%0d%0a++++++++++++++++%3cFontSize%3e11%3c%2fFontSize%
++++++++%3cIsControlEnabled%3efalse%3c%2fIsControlEnabled%3
ext+%2f%3e%0d%0a++++++++++++++++%3cHeight%
izes%3e0%3c%2fGroupSizes%3e%0d%0a++++++
+++++++++%3cNameIndex%3e62%3
%0a++++++++++++++++
2f%3e%0d%0a++++
%0d%0a++++++++++++++%3c%2fTD%3e%0d%0a++++++++++++++%3cTD%3e%0d%0a+
0a++++++++++++++++%3cColSpan+%2f%3e%0d%0a++++++++++++++++%3c
+++++++++++++++%3cFontSize%3e11%3c%2fFontSize%3e%0d%0a++++
ight%3e15%3c%2fHeight%3e%0d%0a++++++++++++++++%3cA
1%3c%2fX%3e%0d%0a++++++++++++++++%3cY%3e6
cGroupSeparator+%2f%3e%0d%0a+++++++++
++++++++++++++++%3cPSCForma
enter%3c%2fVerticalAlign%3e
d%0a+++++++++
ntSize%3e%0d%0a++++++++++++++++%3cX%3e21%3c%2fX%3e%0d%0a++++++++++++
++%3cAlign%3eCenter%3c%2fAlign%3e%0d%0a++++++++++++++++%3cVerticalAli
f%3e%0d%0a++++++++++++++++%3cHeight%3e15%3c%2fHeight%3e%0d
FontName%3eCalibri%3c%2fFontName%3e%0d%0a+++++++++++
++++++++++++++++%3cRowSpan+%2f%3e%0d%0a++
mated%3efalse%3c%2fPSCFormated%3e%0d%0a+
+++++++%3c%2fTD%3e%0d%0a+++
d%3efalse%3c%2fPSCFormate
ntName%3eCalibri%
+++++++++%3cText+%2f%3e%0d%0a++++++++++++++++%3cHeight%3e15%3c%2fHeight
%3e15%3c%2fHeight%3e%0d%0a++++++++++++++++%3cAlign%3eLeft%3c%2fAlign%3e%0d%0a++++
n%3e%0d%0a++++++++++++++++%3cVerticalAlign+%2f%3e%0d%0a++++++++++++++++%3cCellH
 Follow the steps to enable your Medical History Form.
>> Your Medical History Form is ready to use. Following steps are for online use.
2) 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 th
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
>> 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/

y Form.

created automatically.

e form will be saved on the "Data" tab.

24d9e2e4-128a-4757-be92-e96be55967e4