Attach. B-sf93_e.pdf

MEDICAL RECORD REPORT OF MEDICAL HISTORY

DATE OF EXAM

NOTE: This information is for official and medically-confidential use only and will not be released to unauthorized persons

1. NAME OF PATIENT (Last, first, middle) 2. IDENTIFICATION NUMBER 3. GRADE

4a. HOME STREET ADDRESS (Street or RFD; City or Town; State; and ZIP Code) 5. EXAMINING FACILITY

6. PURPOSE OF EXAMINATION

NO. OF ATTACHED SHEETS:

STANDARD FORM 93 (REV. 6-96)

Prescribed by ICMR/GSA

FIRMR (41 CFR) 201-9.202-1

4b. CITY 4c. STATE 4d. ZIP CODE

d. HEIGHT e. WEIGHT

8. PATIENT'S OCCUPATION 9. ARE YOU (Check one)

RIGHT HANDED LEFT HANDED

10. PAST/CURRENT MEDICAL HISTORY

Arthritis, Rheumatism, or Bursitis

Thyroid trouble or goiter

Eating disorder (anorexia bulimia, etc.)

c. ALLERGIES (Include insect bites/stings and common foods)

YES NO

DON'T

KNOW

CHECK EACH ITEM

Scarlet fever

Rheumatic fever

Swollen or painful joints

Frequent or severe headaches

Dizziness or fainting spells

Eye trouble

Hearing loss

Suicide attempt or plans

Sleepwalking

Wear corrective lenses

Stutter or stammer

Wear a brace or back support

Lack vision in either eye

Wear a hearing aid

Eye surgery to correct vision

Household contact with anyone with tuberculosis

Tuberculosis or positive TB test

Blood in sputum or when coughing

Excessive bleeding after injury or dental work

Recurrent ear infections

Chronic or frequent colds

Severe tooth or gum trouble

Sinusitis

Hay fever or allergic rhinitis

Head injury

YES NO

DON'T

KNOW

CHECK EACH ITEM

Kidney stone or blood in urine

Sugar or albumin in urine

Sexually transmitted diseases

Recent gain or loss of weight

Jaundice or hepatitis

Broken bones

Adverse reaction to medication

Tumor, growth, cyst, cancer

Hernia

Hemorrhoids or rectal disease

Frequent or painful urination

Bed wetting since age 12

Shortness of breath

Pain or pressure in chest

Chronic cough

Palpitation or pounding heart

Heart trouble

High or low blood pressure

Cramps in your legs

Frequent indigestion

Gall bladder trouble or gallstones

Asthma

CHECK EACH ITEM

Asbestos or toxic chemical exposure

Plate, pin or rod in any bone

Easy fatigability

Been told to cut down or criticized for alcohol use

Used illegal substances

Used tobacco

"Trick" or locked knee

Loss of finger or toe

Painful or "trick" shoulder or elbow

Recurrent back pain or any back injury

Foot trouble

Nerve Injury

Paralysis (including infantile)

Epilepsy or seizure

Car, train, sea or air sickness

Frequent trouble sleeping

Depression or excessive worry

Loss of memory or amnesia

Nervous trouble of any sort

Periods of unconsciousness

Parent/sibling with diabetes, cancer, stroke or heart disease

X-ray or other radiation therapy

Chemotherapy

YES NO

DON'T

KNOW

Stomach, liver or intestinal trouble

Skin diseases

Bone, joint or other deformity

NSN 7540-00-181-8368

Previous edition not usable

7. STATEMENT OF PATIENT'S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED (Use additional pages if necessary)

a. PRESENT HEALTH b. CURRENT MEDICATION REGULAR OR INTERM.

25. PHYSICIAN'S SUMMARY AND ELABORATION OF ALL PERTINENT DATA (Physician shall comment on all positive answers in Items 7 through 11. Physician may develop by interview any additional medical history deemed important, and record any significiant findings here.)

26c. DATE26a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER 26b. SIGNATURE

STANDARD FORM 93 (REV. 6-96) BACK

12. Have you been refused employment or been unable to hold a job or stay in school because of:

a.Sensitivity to chemicals, dust, sunlight, etc.

b.Inability to perform certain motions.

c. Inability to assume certain positions.

d.Other medical reasons (If yes, give reasons.)

13. Have you ever been treated for a mental condition? (If yes, specify when, where, and give details.)

14. Have you ever been denied life insurance? (If yes, state reason and give details.)

15. Have you had, or have you been advised to have, any operation.

(If yes, describe and give age at which occurred.)

16. Have you ever been a patient in any type of hospital? (If yes, specify when, where, why, and name of doctor and complete address of hospital.)

17. Have you consulted or been treated by clinics, physicians, healers, or other practitioners within the past 5 years for other than minor illnesses? (If yes, give complete address of doctor, hospital, clinic, and details.)

18. Have you ever been rejected for military service because of physical, mental, or other reasons? (If yes, give date and reason for rejection.)

19. Have you ever been discharged from military service because of physical, mental, or other reasons? (If yes, give date, reason, and type of discharge; whether honorable, other than honorable, for unfitness or unsuitability.)

20. Have you ever received, is there pending, or have you ever applied for pension or compensation for existing disability? (If yes, specify what kind, granted by whom, and what amount, when, why.)

21. Have you ever been arrested or convicted of a crime, other than minor traffic violations. (If yes, provide details.)

22. Have you ever been diagnosed with a learning disability? (If yes, give type, where, and how diagnosed.)

I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my knowledge. I authorize any of the doctors, hospitals, or clinics mentioned above to furnish the Government a complete transcript of my medical record for purposes of processing my application for this employment or service. I understand that falsification of information on Government forms is punishable by fine and/or imprisonment.

24c. DATE24a. TYPED OR PRINTED NAME OF EXAMINEE 24b. SIGNATURE

NOTE: HAND TO THE DOCTOR OR NURSE, OR IF MAILED MARK ENVELOPE "TO BE OPENED BY MEDICAL OFFICER ONLY".

23. LIST ALL IMMUNIZATIONS RECEIVED

11. FEMALES ONLY

CHECK EACH ITEM

Treated for a female disorder

Change in menstrual pattern

DATE OF LAST MENSTRUAL

PERIOD

DATE OF LAST PAP SMEAR DATE OF LAST MAMMO-

GRAMYES NO

DON'T

KNOW

CHECK EACH ITEM. IF "YES" EXPLAIN IN BLANK SPACE TO RIGHT. LIST EXPLANATION BY ITEM NUMBER.

YES NOITEM