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Wellness Family Medicine
DATE OF BIRTH:                                     PHONE:                                       MARITAL STATUS:
ADDRESS:                                                                                                  SEX:  MALE    FEMALE
Job Title
# Do you have or have you ever had the following?  (Please check the appropriate box for each item.) Now Past Never Please supply details in the space below for questions where "Now" or "Past" is checked.  List by question number.
1 High blood pressure
2 Heart attack or other heart problem
3 Heart murmur
4 Cough that lasted more than a month
5 Chest pain
6 Shortness of breath
7 Palpitations or irregular heart beat
8 Bleeding tendency
9 Cancer or tumors
10 Diabetes (“sugar”)
11 Vision problems, including glasses or contacts
12 Eye problems, diseases or injuries
13 Hernia or rupture.
14 Hearing problems
15 Use of tobacco products
16 Any problems with kidneys or bladder, including frequent infections
17 Ulcer or vomiting blood
18 Liver disease or Hepatitis
19 Bowel Changes/Rectal Bleeding
20 Diarrhea for more than three days
21 Hepatitis B vaccine
22 Tuberculosis
23 Chickenpox
24 HIV infection / AIDS
25 TB test in the last year
26 Positive TB skin test
27 Back problems or pain
28 Trouble bending or twisting
29 Lower or upper back injury
30 Leg pain or numbness
31 Neck problems or pain
32 Pain or difficulty with neck movement
33 Neck injury
34 Arm pain or numbness
35 Spine surgery
36 Shoulder pain or limited motion
37 Shoulder surgery
38 Shoulder injury
39 Knee pain, swelling, locking or weakness
40 Knee surgery
41 Knee injury
42 Carpal tunnel syndrome diagnosis, treatment or surgery
43 Numbness or pain of the hands or wrists
Name:                                                     SSN:                                        Date:            
# Do you have or have you ever had the following?  (Please check the appropriate box for each item.) Now Past Never Give details by question number for "Now", "Past" or "Yes."
44 Fractures or broken bones
45 Other injury or problem with arms or legs
46 Arthritis or joint problems
47 Ankle or foot problems
48 Alcoholism or Drinking Problem
49 Frequent or severe headaches/migraines
50 Brain or Nervous System Problems
51 Psychiatric or emotional disorder
52 Dizziness or fainting
53 Epilepsy, seizures or fits
54 Stroke
55 Head injury
56 Drug abuse treatment
57 Muscle weakness
58 Problems with balance or coordination
59 Tremor or shaking
60 Difficulty walking more than a block
61 Exposure to hazardous chemicals, drugs or dust
62 Allergies to medications, latex, foods, pollens, danders, cosmetics, jewelry or other substances
63 Atopic dermatitis, psoriasis or eczema
64 Other rash or skin problem
65 Asthma, wheezing or hay fever
66 Intolerance to perfumes or strong scents
67 Other serious disease
68 Other surgery
69 Other hospitalized overnight
70 Other health problem or concern
Please answer "Yes" or "No" Yes No
71 Have you ever had a work injury or Worker’s Compensation claim?
72 Have you ever been refused employment or been unable to hold a job (including military) because of:
73 a. Sensitivity to chemicals, latex, etc.
74 b. Inability to perform certain motions
75 c. Other physical or mental reasons
76 Have you ever required special or restricted job assignments due to illness, injury, or physical impairments?
77 Have you had a previous job with similar physical demands?
78 Are you under a doctor’s care?
79 Lost 10 pounds or more in the last year
80 Are you pregnant?
List all medications you have taken in last month:
I hereby affirm that the information above is true to the best of my knowledge and belief.  I agree that any false statement or misrepresentation will be cause for dismissal.   Date _____________  Signature ________________________________

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