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EFD Medical History Form

IDENTIFICATION INFORMATION
HAVE YOU HAD ANY SURGERIES/OPERATIONS...
on your back, arm, leg or knee:
to treat a hernia:
Other operations:
Have you ever been hospitalized:
ALLERGY - HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE...
serious allergies:
a bad reaction to any medication:
Have you ever been advised not to take any medication (i.e.Aspirin):
SKIN - HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE...
hives/eczema or rash:
chronic skin problems (i.e. cuts slow to heal):
excessive dry skin:
problems with easy bruising:
chemical or jewelry rash/sensitivity:
NEURO - HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE...
psychiatric or emotional problems:
numbness/weakness/paralysis:
dizziness or fainting spells:
severe/frequent migraine headaches:
a head injury, concussion, or skull fracture:
any neurological disorders:
seizures or blackouts:
a stroke:
EYES & EARS - HAVE YOU EVER HAD OR HAVE YOU CURRENTLY HAVE...
hearing loss:
frequent ear infections:
tinnitus (ringing in the ears):
other ear problems:
glaucoma or cataracts:
problems with eye redness:
other eye problems:
glasses/contacts:
HEAD/NECK - HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE...
problems with teeth or dentures:
frequent mouth ulcers/infections:
sinus or hay fever problems:
frequent sore throats:
frequent nose bleeds:
trouble with your thyroid (i.e. taking thyroid medications):
problem requiring radiation treatment to the neck area:
LUNGS - HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE...
asthma or wheezing:
coughing up blood:
shortness of breath without apparent reason:
TB or positive skin test for TB:
pneumonia or pleurisy:
cough every day, especially in the morning:
Pain or tightness in chest:
More than 3 episodes of bronchitis in 1 year:
Ever smoked tobacco in any form:
HEART - HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE...
Rheumatic fever or heart murmur:
Heart Disease:
Treated for heart condition:
Unusually cold or bluish colored hands or feet:
High blood pressure:
Do you have a history of elevated cholesterol:
Anemia or any blood disease:
Phlebitis, varicose veins, or blood clots/poor circulation:
Chest pain with activity:
GI - HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE...
Ulcers:
Hiatal Hernia:
Indigestion, pain or unusual burning in stomach:
Vomiting of blood:
Bloody/tarry bowel movements:
Colitis or nervous stomach:
Problems with your pancreas:
Gallbladder disease:
KIDNEYS - HAVE YOU EVER HAD OR DO YOU CURRENTLY HAVE...
Bladder or Kidney Infections:
Kidney stones:
Burning or discomfort on urination or frequent urination:
Hernia:
Blood in urine:
MISCELLANEOUS - HAVE YOU HAD OR DO YOU CURRENTLY HAVE...
Diabetes or sugar in your blood or urine:
Cancer of any kind:
MUSCLE SKELETAL - HAVE YOU HAD OR DO YOU CURRENTLY HAVE...
Arthritis, rheumatism, neck, back, spine injury or disease:
Been treated for back problem:
Recurrent stiffness or back pain:
Bursitis, tendonitis:
Recurrent pulled muscles or sprains:
Hand or wrist injury or problems:
Hip or knee injury or problem:
Ankle or foot injury or problem:
Frostbite:
Job Requiring Heavy Lifting or Standing or Sitting for Long Periods or Time:
Any Broken Bones:
FOR FEMALES ONLY - HAVE YOU HAD OR DO YOU CURRENTLY HAVE...
Menstrual Irregularities:
Recurrent Problems of the Female Organs:
Breast Masses or Lumps:
Do You Practice Monthly Breast Self Exam:
Have You Ever Had a Mammogram:
FemaleOnlyComments
FOR MALES ONLY - HAVE YOU HAD OR DO YOU CURRENTLY HAVE...
Prostate or Testicular Problems:
Breast Tenderness, Swelling, or Lumps:
Do You Practice Monthly Testicular Self-Exam:
GENERAL LIFESTYLE I - Check the Answer That Best Describes You
General Health:
% of Seatbelt Use:
Daily Stress:
Average Hours of Sleep:
Average Meals Daily:
Number of Eggs Per Week:
Average Number of Red Meat Meal Per Week:
Average Number of Alcohol Beverages/Beers Per Week:
Do You Exercise Three Times Per Week? 30-40 Minutes Each Time:
Are You More Than 30% Above Your Ideal Weight:
Have You Been Immunized Against Hepatitis B:
Do You Take Any Prescription Medication:
Do You Take Any Non-Prescription Medication (or Over The Counter) Drugs on a Regular Basis:
GENERAL LIFESTYLE II
Do You Participate in a Workplace Wellness Help Promotion Program:
Which of the following would you participate in, if offered
Cholesterol Screen:
Blood Pressure Screen:
Weight Loss:
Nutrition Program:
Stress Management:
Smoking Cessation:
CPR Classes:
Blood Drive:
Health Risk Appraisal:
Health Education Program:
Women's Health:
WORK HISTORY I - HAVE YOU EVER...
Been Restricted in Your Work or Given "Light Duty" Because of Your Health or Injury:
Left a Job Because of Health Problems:
Been Injured on the Job and Treated by a Doctor:
Received Compensation for an Industrial Injury or Illness:
Are You Receiving Any Health Care Treatment (i.e., Physician Therapy, Chiropractic, Acupuncture, Medical, etc.):
Been Hospitalized in the Last Five Years:
Have you had any illness or injury that we have not asked you about:
Confirmation
I certify that the above information is complete to the best of my knowledge. I hereby give permission to release work related information to the proper authorities of my employer.:
 
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