Patient: ___________________________________________                                               MEDICAL ALERT

 

Do you have, or have you ever had any of the following?

 

Heart murmur  ........................................................…................................................................................  Yes   No

High blood pressure   .................................................................................................................................  Yes   No

Low blood pressure   ..................................................................................................................................  Yes   No

Rheumatic fever   ......................................................................................................................................   Yes   No

Prosthetic joints  .........................................................................................................................................  Yes   No

Allergies (including latex)...........................................................................................................................  Yes   No

 

   To what? ________________________________________________________________________________

 

Hay fever  .............................................................….................................................................................  Yes   No

Asthma  ..................................................................…...............................................................................  Yes   No

Bronchitis  ...........................................................….............................................................................….  Yes   No

Emphysema  ........................…..............................…................................................................................  Yes   No

Tuberculosis  .........................................................…................................................................................  Yes   No

Sinus problems   .....................................................…...............................................................................  Yes   No

Fainting spells or seizures  .....….............................…..............................................................................  Yes   No

Diabetes  ..............................................................…................................................................................... Yes   No

Persistent diarrhea or recent weight loss  ....................…..........................................................................  Yes   No

Eating disorders  ..................................................…..................................................................................  Yes   No

Hepatitis, jaundice or liver disease   ....................................................................................................…... Yes   No

HIV or AIDS  .........................................................….....................................................….......................  Yes   No

Thyroid problems   ...................................................…..............................................................................  Yes   No

Arthritis/painful joints  ...........................................…................................................................................  Yes   No

Stomach ulcers   .......................................................…..............................................................................  Yes   No

Kidney problems   ....................................................…..............................................................................  Yes   No

Persistent cough or coughing up blood   ..................…..............................................................................  Yes   No

Persistent swollen glands in neck   ..........................................................…...............................................  Yes   No

Sexually transmitted disease   ....................................................................................................................  Yes   No

Epilepsy or other neurological disease   ...................…….........................................................................  Yes   No

Mental health problems   .........................................…...................................................................…........  Yes   No

Cancers/tumors/abnormal growths   ...................…......................….........................................................  Yes   No

Immune system problems   ......................................…..............................................................................  Yes   No

Abnormal bleeding   ................................................…...............................................................................  Yes   No

Have you ever had a blood transfusion   ..............…....…..........................................................................  Yes   No

Blood disorders   .....................................................…...............................................................................  Yes   No

Anemia  ...................................................................…................................................................................ Yes   No

Do you smoke  .......................................................….................................................................................. Yes   No

Do you chew tobacco/snuff  ...................................…................................................................................  Yes   No

 

Women

Are you pregnant? .................................................….................................................................................  Yes   No

Do you have any problems associated with your menstrual period? .......….……............................................  Yes   No

Are you nursing? .....................................................…...............................................................................  Yes   No

Are you taking birth control pills? ..............................…...............................................................................  Yes   No

 

Do you have any other medical problems or special needs that we should be aware of? Please explain: ___________________________________________________________________________________________

___________________________________________________________________________________________

 

Patient/Responsible Party Social Security Number: ___________________________

 

Signature ____________________________________________________ Date ________________________

 

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