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    Medical History Form (Only For International Exchange Students)

    Uploaded by

    Ana Romina Delfante Vila
    This medical history form collects information about a patient's personal details, medical history, current medications, and presence of medical conditions. It requests the patient's name, date of birth, sex, place of origin, present address, dates attending the University of Montevideo, and email. It asks the patient to indicate "yes" or "no" for any significant illnesses, operations, treatment by a psychiatrist, or current medications. Finally, it lists various medical conditions and asks the patient to check "yes" or "no" for any previously or currently experienced, and provide details for any items answered "yes".

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Medical History Form (Only For International Exchange Students)

    Uploaded by

    Ana Romina Delfante Vila
    18 views1 page
    This medical history form collects information about a patient's personal details, medical history, current medications, and presence of medical conditions. It requests the patient's name, date of birth, sex, place of origin, present address, dates attending the University of Montevideo, and email. It asks the patient to indicate "yes" or "no" for any significant illnesses, operations, treatment by a psychiatrist, or current medications. Finally, it lists various medical conditions and asks the patient to check "yes" or "no" for any previously or currently experienced, and provide details for any items answered "yes".

    Original Title

    Medical_History_Form_(Only_for_international_exchange_students)

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    © © All Rights Reserved

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    This medical history form collects information about a patient's personal details, medical history, current medications, and presence of medical conditions. It requests the patient's name, date of birth, sex, place of origin, present address, dates attending the University of Montevideo, and email. It asks the patient to indicate "yes" or "no" for any significant illnesses, operations, treatment by a psychiatrist, or current medications. Finally, it lists various medical conditions and asks the patient to check "yes" or "no" for any previously or currently experienced, and provide details for any items answered "yes".

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    18 views1 page

    Medical History Form (Only For International Exchange Students)

    Uploaded by

    Ana Romina Delfante Vila
    This medical history form collects information about a patient's personal details, medical history, current medications, and presence of medical conditions. It requests the patient's name, date of birth, sex, place of origin, present address, dates attending the University of Montevideo, and email. It asks the patient to indicate "yes" or "no" for any significant illnesses, operations, treatment by a psychiatrist, or current medications. Finally, it lists various medical conditions and asks the patient to check "yes" or "no" for any previously or currently experienced, and provide details for any items answered "yes".

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    MEDICAL HISTORY FORM

    1. NAME:
    Last First Other
    2. DATE OF BIRTH: __________________________________________
    3. SEX:  Male  Female
    Month/Day/Year
    4. PLACE OF ORIGIN OR PERMANENT RESIDENCE:____________________________________________________________________________
    City Country
    5. PRESENT ADDRESS: ____________________________________________________________________________________________________
    Home or Residence City Country
    6. Email Address:_____________________________________________ 7. DATES at UM:_____________________________________________
    From To

    8. Indicate “YES” or “NO”

    YES NO EXPLANATION
    (a) Have you ever had any significant or serious illness (es)
    or injuries? (State nature of problems/places/dates.)
    (b) Have you ever had any operations or been advised by a
    physician to have an operation? (Describe and give
    places/dates.)
    (c) Have you ever been a patient in a mental hospital or
    sanitarium or treated by a psychiatrist? (Give
    places/dates.)
    (d) Do you currently take medication for treatment of a
    medical condition (list name/dose) or do you require the
    use of a medical device?

    9. Do you now have or have you ever had any of the conditions listed below? (Check “YES” or “NO” for each Item.)

    YES NO CHECK EACH ITEM YES NO

    (a) Epilepsy, convulsions, fits.


    (m) Tropical diseases (malaria, bilharzia, amoebiasis,
    leprosy, filariasis, yaws, etc.).
    (b) Eye disease, vision defect in one or both eyes.

    (c) Tooth or gum disease (periodontal disease).


    (n) Depression, anxiety, attempted suicide or other
    psychological symptoms.
    (d) Asthma, emphysema, or other lung conditions.

    (e) Tuberculosis or exposure to tuberculosis.


    (o) Drug or narcotic habit such as marijuana, cocaine,
    heroin, LSD, or any derivatives.
    (f) High/low blood pressure, heart disease.
    (o) Drug or narcotic habit such as marijuana, cocaine,
    (g) Stomach, liver (hepatitis), gallbladder disease.
    heroin, LSD, or any derivatives.
    (h) Hernia (rupture)/Genito-Urinary/Rectal (p) Bleeding disorder. blood disease, sickle cell
    Disorder. anemia.
    (i) Kidney or bladder condition, stone or blood. (q) Tumor, abnormal growth, cyst, or cancer.

    (j) Diabetes, sugar in the urine. (r) Skin disorder growths psoriasis.

    (k) Joint disease or injury, swollen or painful joints. (s) Gynecological disease/abnormal menses.
    (l) Back pain, or spinal condition, use of back
    (t) Hearing impairment.
    brace.

    10. If you answered “YES” to any item in Question 9, please explain in detail (include dates of occurrence, treatment, and outcome):

    Medical History Form – Universidad de Montevideo

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