Medical History. Relevant physical health conditions reported by the beneficiary or a significant support person. Include name and address of current source of medical treatment. For children and adolescents, the history must include prenatal and perinatal events and relevant/significant developmental history. If possible, include other medical information from medical records or relevant consultation reports;
Medical History. Collect medical history information, including information on all medications used within the past 30 days. Include herbal therapies, vitamins, and all over-the-counter as well as prescription medications. Throughout the subject’s participation, obtain information on any changes in medical health and/or the use of concomitant medications. Medical History and Concomitant Medications will be collected in the eCRF as outlined in the MOP.
Medical History. All statements concerning my medical history, insurance information and emergency contacts in the medical history that follows are current, accurate, and complete (use additional sheets if necessary). I understand that I am required to carry a complete medical history on my person at all times during the course of the Performance Tour. The following information is a full and correct statement of my medical history:
Medical History. Do you have any medical history, allergies or medications which you would like us to have on record? [ ] No [ ] Yes, explain: TRAVEL INSURANCE: Baggage, accident, medical and trip cancellation/interruption insurance is recommended. Crafty Gemini LLC cannot be responsible for extra expenses due to delays and changes in your itinerary for reasons beyond our control. I understand that I may purchase travel insurance for baggage, accident, medical and trip cancellation/interruption refunds through a travel insurance company (consult with you travel agent) and [ ] I DO or [ ] I DO NOT intend to obtain travel insurance to cover any losses related to a 2023 Crafty Gemini Sewing/Quilting Retreat.
Medical History. I understand that participation in this activity is NOT recommended for persons who have any allergies or medical conditions or problems such as heart condition, seizures, high blood pressure, stomach problems, joint problems, hearing difficulty, breathing condition, diabetes, back problems, vision problems, migraines, dizziness, poor circulation, arthritis, toothaches, past surgery, or any other medical condition or difficulty that would prevent me from safely participating in this event. If I or the participant named below has any of these or other conditions or problems and still chooses to participate in this activity, I assume all risks associated with such participation. Release of Photographs: I understand that photographs and/or videotapes of me and my family members may be taken for use in promoting the City of Xxxxx activities and facilities in future editions of CenterPoint, in a variety of other publications, on signage throughout the Community Center, and for other uses by the City of Xxxxx. I hereby give my permission to use such photographs without compensation to me. With clear knowledge of the risks involved in participation with the indoor rock climbing facility, including, but not limited to those outlined herein, I voluntarily assume all risks associated with participation, known or unknown, and I agree to follow all safety policies and procedures established by the City of Xxxxx for participation with the indoor rock climbing facility. I further certify, acknowledge and agree that the participant named below is of the physical, emotional and mental capability necessary for participation with the indoor rock climbing facility, at the present date and any future date.
Medical History. Has your medical history been normal/unremarkable? Yes No If no, please explain: Have you received any medical diagnoses? Yes No Please explain: Circle All that Apply: Yes No Have you completed genetic testing? Yes No Have you had an MRI? Yes No Have you had an EEG? Yes No Frequent ear infections? Yes No Were ear tubes ever placed? Yes No Hearing problems? Yes No Vision problems? Yes No Headaches? Yes No Meningitis? Yes No Seizures? XxXxxxxxx Assessment and Psychological Services xxxxxxxxxxxxxxxx@xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.xxx 000-000-0000 Yes No Asthma? Yes No Slow/fast growth? Yes No Head injury? Yes No Allergies? Yes No Hospitalizations? Yes No Have you experienced anything you would call traumatic (physical, verbal, or emotional abuse; unwanted sexual experiences; accidents or other events)? Have you ever been hospitalized, had surgeries, or major illnesses? Age How long Reason What medications do you currently take? (Include over-the-counter supplements) Name Dose Frequency Reason Describe your sleep routine: Typical bed time: Typical wake time: Trouble falling asleep? Yes No Trouble staying asleep? Yes No Trouble waking up early? Yes No Any other sleep problems? Explain: Describe your diet: Describe your current level and type(s) of exercise: Mental Health History List any previous or current mental health diagnoses: Have you received therapy services or counseling in the past? Yes No Name of provider: Dates: Name of provider: Dates: Name of provider: Dates: Are you seeing a psychiatric clinician (Psychiatrist, Nurse Practitioner, Physician Assistant) for medication? Yes No Have you in the past? Yes No Name of Clinician: Dates of treatment: Medication(s) Prescribed: Is there a history of self-harm or suicidal thoughts, threats, or attempts? Please explain: Have you ever been hospitalized for mental health concerns? Please explain: Do you have a history of angry outbursts? Yes No If yes, please explain: Have you ever physically assaulted another person, animal, or object? Yes No If yes, please explain: Psychosocial Functioning Describe your personality: What are your non-academic strengths? What are your non-academic weaknesses? How do you spend your free time? What is your current level of alcohol and/or drug use?
Medical History. Patient Name: Date: / / What skin issue are you here for: Are you ALLERGIC to LATEX? YES NO If Yes, explain reaction: Have you ever had a SKIN CANCER? YES NO If YES, Circle Type: MELANOMA BASAL CELL CARCINOMA SQUAMOUS CELL CARCINOMA Is there a FAMILY HISTORY of MELANOMA: YES NO Who? Is there a FAMILY HISTORY of Other SKIN CANCER : YES NO Who? Have you ever been diagnosed with HIGH BLOOD PRESSURE (hypertension) or DIABETES? : YES NO Are you taking ASPIRIN, MULTI-VITAMINS, FISH OIL or HERBAL SUPPLEMENTS?: YES NO Do you currently use Nicotine? YES NO How many yrs? Tobacco Vaping electronic pen Are you ALLERGIC to any medicines? YES NO If Yes, please list: MEDICATION ALLERGY REACTION MEDICATIONS and SUPPLEMENTS/HERBALS you are currently taking : NONE
Medical History. Do YOU have a present or past history of the following: (check all that apply) Alcohol abuse Anemia Arthritis Asthma Back problems Cancer Colitis Convulsions/Seizures Cough (chronic) Depression Diabetes Disability/Handicap Drug abuse Ear trouble/hearing loss Eating disorder Eye disease/problems Gallbladder trouble Hay fever (recurrent) Head injury Headache (recurrent) Heart disease/problems Hepatitis/Jaundice Hernia/rupture High blood pressure Intestinal/stomach trouble Joint disease/injury Measles, Red Menstrual problems Migraine headaches Mononucleosis, infectious Mumps Pneumonia Paralysis Polio Psychological counseling Rheumatic fever Rubella (3-daymeasles) Scarlet fever Sexually trans. infection(STI) Sickle Cell Trait/Anemia Sinus trouble Skin problems (chronic) Sleep problems Smoking (how long?) Spleen, surgical removal Thyroid disease Tuberculosis Urinary tract infection Other NONE OF THE ABOVE Current medications (list all, including birth control) Do youhaveallergies to drugs, foods, metals? Yes/ No What are they? Hospitalizations/surgeries N/A N/A N/A Family history (place relationship in blank) Alcohol/drug abuse Cancer/type Death before 50 Diabetes Elevated cholesterol Heart disease — 2 — Hypertension/stroke Mental illness UPWARD BOUND PARENTAL CONSENT FOR MEDICAL TREATMENT Student’s Name In case of emergency, please contact the following: Physician Phone number 1st person to contact in case of emergency Home phone Work Phone Cell phone Address Relationship to student 2nd person to contact in case of emergency Home phone Work Phone Cell phone Address Relationship to student 3rd person to contact in case of emergency Home phone Work Phone Cell phone Address Relationship to student Please describe any allergies or dietary restrictions or needs your child may have: Please list ALL medicines/prescriptions your child will take/is currently taking: Medication/Prescription Dosage Time What are (if any) the anticipated side effects and/or drug interactions from these medications? Please describe any dietary restrictions or needs your child may have: Parent/Guardian printed name Parent/Guardian date of birth Date Tuberculosis (TB) Screening questionnaire Have you ever had a positive TB skin test? Have you ever had close contact with anyone who was sick with TB? YES NO YES NO Were you born in one of the countries listed below and arrived in the U.S. within the past 5 years? (If yes, please CIRCLEthe country) YES NO Have you ever traveled to/in one or more...
Medical History. Approximate last date and reason you visited the doctor Please list any significant past or current health, medical, or psychiatric issues (including anything resulting in hospitalizations): Approximate Dates Problem & Treatment Hospitalized (Y/N) How Long? If applicable, please list all medications you are now taking or have taken in the past three months, including birth control pills, vitamins, herbs, and supplements. Medication Dosage Person prescribing How long Helpful (Y/N) Have any members of your current or original family had problems with: (check all that apply) Family Member Depression Anxiety Other mental illness Alcohol /Drugs Learning problem Seizures Heart Disease Cancer Other Illness (Specify) Mother Father Sibling Aunt/Uncle Cousin Spouse Child If applicable, number of caffeinated beverages you consume per day: coffee soda tea If applicable, number of cigarettes smoked per day: If applicable, how often do you use marijuana per week? Consider a typical week during the past month. Please fill in a number for each day of the week indicating the typical number of alcoholic drinks you usually consume on that day and the typical number of hours you usually drink on that day. Note: 1 Drink = 12 oz. beer / 10 oz. microbrew / 8 oz. malt liquor or 4 oz. of wine /1 o hard alcohol (shot glass) Approximate: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Number of drinks Number of hours drinking In the past year, have you taken any medications other than as prescribed or used any recreational drugs other than marijuana? If yes, please list (this information will be kept in confidence along with everything else in this form): Have you dealt with gambling, pornography, internet/gaming overuse, or other addictions? Have you ever experienced: (Please mark all that apply) Emotional abuse Physical abuse Sexual abuse Sexual assault Comments:
Medical History. Current prescribed medications/dosage: Prescribing physician(s): Past hospitalizations, surgeries, medical issues Current medical issues: Allergies: None known Ongoing physical pain? Yes No Frequency? Location? When began? Intensity (0 none -10 extreme) Physical disabilities or limitations of movement, sight, or hearing? Yes No If yes, explain Abuse: History of being sexually abused? Yes No History of being physically abused? Yes No If yes, state relationship to the abuser. Date(s) of abuse Was the abuse reported? Yes No If yes, to whom? Any abuse of any kind to other members of family? Yes No If yes, to whom?
