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EFD Medical History Form

Identification Information

Health History

On your back, arm, leg, knee:
To treat a hernia:
Other operations:
Have you ever been hospitalized:
Serious allergy:
Bad reaction to any medication:
Advised not to take any medication (i.e.Aspirin):
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:
A psychiatric or emotional problem:
Dizziness or fainting spells:
Severe/frequent migraine headaches:
Head injury, concussion, or skull fracture:
Neurological disorders:
Seizures or blackouts:
Hearing loss:
Frequent ear infections:
Ringing in ears:
Other ear problems:
Glaucoma or cataracts:
Red eyes:
Other eye problems:
Recent problems with teeth or dentures:
Frequent mouth ulcers/infections:
Sinus or hay fever:
Frequent sore throats:
Frequent Nose Bleeds:
Trouble with thyroid (i.e. taking thyroid medications):
Problem requiring radiation treatment to the neck area:
Asthma or wheezing:
Coughing up any blood:
Shortness of breath without apparent reason:
TB or positive skin test for TB:
Pneumonia or Pleurisy:
Do you 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:
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:
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:
Bladder or Kidney Infections:
Kidney stones:
Burning or discomfort on urination or frequent urination:
Blood in urine:
Diabetes or sugar in your blood or urine:
Cancer of any kind:
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:
Job Requiring Heavy Lifting or Standing or Sitting for Long Periods or Time:
Any Broken Bones:
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:
Prostate or Testicular Problems:
Breast Tenderness, Swelling, or Lumps:
Do You Practice Monthly Testicular Self-Exam:

General Lifestyle I

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:
Cholesterol Screen:
Blood Pressure Screen:
Weight Loss:
Nutrition Program:
Stress Management:
Smoking Cessation:
Blood Drive:
Health Risk Appraisal:
Health Education Program:
Women's Health:

Work History

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:


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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