Admission Medical Information Form
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1 Return Form to: Admission Medical Information Form Part I: To Be Completed by Family or Staff of Birth: Sex: M F Race: Marital Status: Home Address: Phone Number: Number/Street City State Zip Last Time Hospitalized: Name and Location of Hospital: (s) Reason Last Visit to Physician: (s) Reason Name and Address of Primary Physician: (Comment: YES, NO, SEVERE) Frequent headaches Difficulty with vision Difficulty with hearing Tuberculosis Pneumonia Asthma or hay fever Persistent cough Cough producing blood Pain in chest Smokes Alcohol consumption Unprescribed drugs Fatigue Anemia Frequent colds/infections Nervous breakdown Convulsions Fainting Jaundice High blood pressure Spasticity of extremities Frequent vomiting Measles (2 weeks) Measles (3 days) Chicken pox Shortness of breath Fever or night sweats Unusual gain or loss of weight Burning on urination Frequent indigestion Diarrhea or constipation Diabetes Special diets Speech defect Color blindness Venereal disease Rheumatic fever Blood in urine Kidney disease Accidents Fractures Arthritis Hernia Transfusion Incontinence of bowel Incontinence of bladder Nosebleeds Mumps Form C-50 Rev. 03/14 Page 1 of 5
2 Menstruating? G Yes G No Age Began: Frequency: Duration: Severity: Any Female Surgery? Any Pregnancies? G Yes G No If yes, what? Birth Control? G Yes G No If yes, type: Seizures? G Yes G No Type: Frequency: Allergies (food/medicine/other)? G Yes G No Type: Type: Severity: Severity: Accidents (Specify): Operations for (Specify): Fractures of (Specify): Developmental History: Prenatal: Natal: New Born: Childhood: Adulthood: Ambulation: Ambulatory G Yes G No Non-ambulatory G Yes G No Type of assistance device: CHECK ALL THAT APPLY: Able to climb onto: Van School Bus Car Transit Bus If assistance is required, please explain: Part I Completed By: : Relationship to Client: Form C-50 Rev. 03/14 Page 2 of 5
3 Admission Medical Information Form Part I: Physical Examination (To Be Completed by physician) Vital signs: BP P R T Blood Type (if known) Height (w/o shoes): Weight (with/without clothes): General Appearance: Nutritional Status: Check and Note Abnormalities for the Following: Head Skin Glands/Thyroid Heart/Cardiovascular Eyes: Vision Screening: Right Eye Left Eye Test Used: Conjunctiva Sclera Cornea Pupils Lens Fundi Ears: Auditory Acuity: Right Left Bilateral Test Used: Canals Drums Abdomen Nose Teeth/Gums Neck Lungs Chest Genitalia Neurological: Orientation State of Consciousness Pathological Reflexes Gait Involuntary Movements Seizures? G Yes G No Description Nodes Skeletal System Breast Gyn Rectal Joints Extremities Cranial Nerves DTR Muscle Strength Tone Physician managing disorder (if other than examining physician) Last Neurological Evaluation Anticonvulsant Levels Last seizure/frequency Prosthetic Devices? G Yes G No Is there any physical, emotional, mental reason why this person cannot board or debark a bus/van? G Yes G No If yes, please explain Form C-50 Rev. 03/14 Page 3 of 5
4 Admission Medical Information Form - Tests Part III: Lab Studies, Immunizations and Medications (To Be Completed by Physician) A. Laboratory Studies Tuberculin: of last PPD: of last chest X-ray: Results: Results: Please attach PPD results. If results are positive, please attach chest x-ray results. Test results must be within one year. Liver Function: (Tests of liver function REQUIRED if client is receiving or has received anticonvulsant or psychotropic medication within the past year.) SGPT SGOT CPK LDH Alkaline Phosphatase Shigella Salmonella Ova & Parasites Hepatitis B Screening: (Note: If client has developed antibodies, either naturally or through vaccination, it is not necessary to repeat this screening.) of Screening: Surface antigen: Negative Positive Surface antibody: Negative Positive Core antibody: Negative Positive Hematocrit Last PAP Test : Results (Note: To be done every three years unless otherwise prescribed.) U/A: Sugar Albumen Ph. SP.Gravity Acetone Microscopic B. Immunization of last Tetanus/Diphtheria Booster: (Should be within last ten years.) Heptavax B Vaccine: Dose #1 Dose #2 Dose #3 Small Pox Poliomyelitis Salk or Sabin Measles Rubella C. Prescribed Medications: G Yes G None (If medications are prescribed, please complete attached Physician s Medication Order Form, C-41. If psychotropic medications a prescribed, please complete Form C-53 Screening Scale for Tardive Dyskinesia also.) Form C-50 Rev. 03/14 Page 4 of 5
5 Admission Medical Information Form Part IV: Diagnosis and Follow Up (To Be Completed by Physician) A. Diagnosis: B. This individual is free of communicable diseases: G Yes G No (If NO please explain) C. If further examination and/or services by specialist(s) are indicated to complete examination and/or diagnosis, specify for which area(s): D. Limitations: Dietary: Physical: Other: E. Recommendations (including diet): F. Other Comments: Examining Physician (please print or type): Physician s Signature: Address: FORM COMPLETED BY (IF OTHER THAN PHYSICIAN): : Phone No: Form C-50 Rev. 03/14 Page 5 of 5
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Pre-participation Physical Examinations www.acsm.org Past Medical History History of any of the following should be made available to the healthcare provider: allergy allergies to medications asthma birth
GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -ORTHO Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
PATIENT INTAKE FORM. Medical History (Please list dates of each instance) Surgeries (Please list approximate dates and Surgeon name)
PATIENT INTAKE FORM Patient Name: Today s Date of Birth: Age: Sex: Male Female Drug Allergies: Yes No Please allergies and reactions: Major Medical Problems (i.e. Diabetes, Heart Problems, etc) Medical