1313 Park Boulevard, Rm. A-180 San Diego, CA 92101
(619)388-3450 office (619)388-3098 fax
revised 12/2019 revised
San Diego City College
Student Health Clinic
MEDICAL HISTORY FORM
Student ID#:________________
Name: _____________________________________________________ Date of Birth: _________________
Last First MI
ALLERGIES: Yes ( ) No ( ) If yes, please list all allergies: _________________________________________
_________________________________________________________________________________________
CURRENT MEDICATIONS: Yes ( ) No ( ) If yes, please list all medications including over-the-counter
medications, herbs, or supplements: ____________________________________________________________
_________________________________________________________________________________________
HOSPTIALIZATIONS: Yes ( ) No ( ) If hospitalized overnight, please list reason and dates: _______________
_________________________________________________________________________________________
SURGERIES: Yes ( ) No ( ) If yes, please list all surgeries and dates: ________________________________
HAVE YOU HAD PROBLEMS WITH ANY OF THE FOLLOWING?
CONDITION
Yes
No
CONDITION
Yes
No
Allergies or “hay fever
Kidney (disease/infections/stones)
Anemia
Migraine headaches
Arthritis or joint problems
Pap smear abnormal
Asthma
Seizure(s)
Autoimmune disorder
Sexually Transmitted Infections
Back problems or injury
Skin (MRSA or other problems)
Bladder infection/UTI
Thyroid
Bleeding disorder
Tuberculosis
Blood clots
Traumatic Brain Injury
Cancer
Ulcer
Concussion
Pregnancy # Live Births #
COPD
Mental Health:
Diabetes
Anxiety
Heart Disease
Depression
Heart Murmur
Eating Disorder
Heavy and/or painful periods
PTSD
Hepatitis
Bipolar
High blood pressure
Other conditions:
High cholesterol
HIV or AIDS
Intestinal problems
1313 Park Boulevard, Rm. A-180 San Diego, CA 92101
(619)388-3450 office (619)388-3098 fax
revised 12/2019
FAMILY HISTORY: Circle if any of the following are present in family members & specify which family members:
Cancer: Heart Disease: Stroke:
Diabetes: High Blood Pressure: Mental Illness:
Autoimmune Disorder: Thyroid Disease: ______
Other
LIFESTYLE REVIEW
Yes
No
Amount
Alcohol
Drinks per day: Per week:
Tobacco
Packs per day: Years of smoking: Quit date:
Drugs
Describe:
Marijuana
Describe:
Previous Substance Use
Describe:
Caffeine
Amount:
Exercise
Type and frequency:
IMMUNIZATION REVIEW
Date of last Tetanus shot: _________________Are your other immunizations up to date? Yes ( ) No ( ) Unsure ( )
MISCELLANEOUS
Yes
No
Yes
No
Are you under the care of another medical
provider or mental health professional?
Glasses or contact lenses
Hearing aid or hearing difficulties
Physical challenge or disability
Speech difficulty
Learning difficulty
Any other pertinent information not included above:
______
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Patient Signature (or signature of Parent/Guardian if under 18 years of age) Date
click to sign
signature
click to edit
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