Fillable Medical History STUDY NAME Visit Record all past (National Institutes of Health)

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Medical History STUDY NAME Visit Record all past (National Institutes of Health)

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Medical History
Medical History Version 1.0
Record all past and/or concomitant medical conditions or surgeries. Record only one condition or surgery per
line using the codes provided in the table. When recording a condition and surgery related to that condition
use one line for the condition and one line for the surgery.
ye Ear, N se, Thr at
to
03 Ca lar
inte
05 Genitourinary
Musc
Neuro
Metabolic
09 Blood/Lymphatic
10 Dermatologic
01 Head, E , o o
02 Respira ry
06 uloskeletal
07 logical
11 Psychiatric
12 Allergy
rdiovascu 08 Endocrine/ 91 Other
04 Gastro stinal
Code
Condition/Diseas
(one item per line)
e
Start Date
dd/mmm/yyyy
Current /
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
Current
Resolved
STUDY NAME
Site Number:
Pt_ID:
_____________________
_____________
Date:
___ ___ / ___ ___ ___ / 2
_
_________
Visit
0 ___ ___
d d m m m y y y y
Visit Type (circle one): Screening Baseline
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Medical History STUDY NAME Visit Record all past (National Institutes of Health)

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Completed 19 July 2020

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