Get Standard Form 93 1996-2024

MEDICAL RECORD REPORT OF MEDICAL HISTORY NO. OF ATTACHED SHEETS DATE OF EXAM NOTE This information is for official and medically-confidential use only and will not be released to unauthorized persons 1. WEIGHT 9. ARE YOU Check one 8. PATIENT S OCCUPATION RIGHT HANDED LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON T KNOW Household contact with anyone with tuberculosis Shortness of breath Chronic cough Blood in sputum or when coughing Palpitation or pounding heart Painful or trick shoulder or elbow Excessive bleeding after injury or dental work High or low blood pressure Recurrent back pain or any back injury Cramps in your legs Trick or locked knee Suicide attempt or plans Frequent indigestion Foot trouble Sleepwalking Stomach liver or intestinal trouble Nerve Injury Wear corrective lenses Gall bladder trouble or gallstones Paralysis including infantile Eye surgery to correct vision Lack vision in either eye Jaundice or hepatitis Car train sea or air sickness Wear a hearing aid Broken bones Frequent trouble sleeping Stutter or stammer Adverse reaction to medication Depression or excessive worry Wear a brace or back support Skin diseases Loss of memory or amnesia Scarlet fever Tumor growth cyst cancer Nervous trouble of any sort Rheumatic fever Hernia Periods of unconsciousness Swollen or painful joints Hemorrhoids or rectal disease Frequent or severe headaches Frequent or painful urination Parent/sibling with diabetes cancer stroke or heart disease Dizziness or fainting spells Bed wetting since age 12 X-ray or other radiation therapy Eye trouble Kidney stone or blood in urine Chemotherapy Hearing loss Sugar or albumin in urine Recurrent ear infections Sexually transmitted diseases Asbestos or toxic chemical exposure Chronic or frequent colds Recent gain or loss of weight Plate pin or rod in any bone Severe tooth or gum trouble Eating disorder anorexia bulimia etc. Loss of finger or toe Tuberculosis or positive TB test Bone joint or other deformity Pain or pressure in chest Easy fatigability Sinusitis Hay fever or allergic rhinitis Heart trouble Head injury Arthritis Rheumatism or Bursitis Asthma Thyroid trouble or goiter NSN 7540-00-181-8368 Previous edition not usable Epilepsy or seizure Been told to cut down or criticized for alcohol use Used illegal substances Used tobacco STANDARD FORM 93 REV. 6-96 Prescribed by ICMR/GSA FIRMR 41 CFR 201-9. 202-1 11. FEMALES ONLY DON T DATE OF LAST MENSTRUAL DATE OF LAST PAP SMEAR KNOW PERIOD DATE OF LAST MAMMOGRAM Treated for a female disorder Change in menstrual pattern ITEM 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. CURRENT MEDICATION REGULAR OR INTERM. c. ALLERGIES Include insect bites/stings and common foods d. HEIGHT e. WEIGHT 9. ARE YOU Check one 8. PATIENT S OCCUPATION RIGHT HANDED LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON T KNOW Household contact with anyone with tuberculosis Shortness of breath Chronic cough Blood in sputum or when coughing Palpitation or pounding heart Painful or trick shoulder or elbow Excessive bleeding after injury or dental work High or low blood pressure Recurrent back pain or any back injury Cramps in your legs Trick or locked knee Suicide attempt or plans Frequent indigestion Foot trouble Sleepwalking Stomach liver or intestinal trouble Nerve Injury Wear corrective lenses Gall bladder trouble or gallstones Paralysis including infantile Eye surgery to correct vision Lack vision in either eye Jaundice or hepatitis Car train sea or air sickness Wear a hearing aid Broken bones Frequent trouble sleeping Stutter or stammer Adverse reaction to medication Depression or excessive worry Wear a brace or back support Skin diseases Loss of memory or amnesia Scarlet fever Tumor growth cyst cancer Nervous trouble of any sort Rheumatic fever Hernia Periods of unconsciousness Swollen or painful joints Hemorrhoids or rectal disease Frequent or severe headaches Frequent or painful urination Parent/sibling with diabetes cancer stroke or heart disease Dizziness or fainting spells Bed wetting since age 12 X-ray or other radiation therapy Eye trouble Kidney stone or blood in urine Chemotherapy Hearing loss Sugar or albumin in urine Recurrent ear infections Sexually transmitted diseases Asbestos or toxic chemical exposure Chronic or frequent colds Recent gain or loss of weight Plate pin or rod in any bone Severe tooth or gum trouble Eating disorder anorexia bulimia etc. Loss of finger or toe Tuberculosis or positive TB test Bone joint or other deformity Pain or pressure in chest Easy fatigability Sinusitis Hay fever or allergic rhinitis Heart trouble Head injury Arthritis Rheumatism or Bursitis Asthma Thyroid trouble or goiter NSN 7540-00-181-8368 Previous edition not usable Epilepsy or seizure Been told to cut down or criticized for alcohol use Used illegal substances Used tobacco STANDARD FORM 93 REV. 6-96 Prescribed by ICMR/GSA FIRMR 41 CFR 201-9. 202-1 11. FEMALES ONLY DON T DATE OF LAST MENSTRUAL DATE OF LAST PAP SMEAR KNOW PERIOD DATE OF LAST MAMMOGRAM Treated for a female disorder Change in menstrual pattern ITEM 12. STATEMENT OF PATIENT S PRESENT HEALTH AND MEDICATIONS CURRENTLY USED Use additional pages if necessary a. PRESENT HEALTH b. CURRENT MEDICATION REGULAR OR INTERM. c. ALLERGIES Include insect bites/stings and common foods d. HEIGHT e. WEIGHT 9. ARE YOU Check one 8. PATIENT S OCCUPATION RIGHT HANDED LEFT HANDED 10. PAST/CURRENT MEDICAL HISTORY CHECK EACH ITEM YES NO DON T KNOW Household contact with anyone with tuberculosis Shortness of breath Chronic cough Blood in sputum or when coughing Palpitation or pounding heart Painful or trick shoulder or elbow Excessive bleeding after injury or dental work High or low blood pressure Recurrent back pain or any back injury Cramps in your legs Trick or locked knee Suicide attempt or plans Frequent indigestion Foot trouble Sleepwalking Stomach liver or intestinal trouble Nerve Injury Wear corrective lenses Gall bladder trouble or gallstones Paralysis including infantile Eye surgery to correct vision Lack vision in either eye Jaundice or hepatitis Car train sea or air sickness Wear a hearing aid Broken bones Frequent trouble sleeping Stutter or stammer Adverse reaction to medication Depression or excessive worry Wear a brace or back support Skin diseases Loss of memory or amnesia Scarlet fever Tumor growth cyst cancer Nervous trouble of any sort Rheumatic fever Hernia Periods of unconsciousness Swollen or painful joints Hemorrhoids or rectal disease Frequent or severe headaches Frequent or painful urination Parent/sibling with diabetes cancer stroke or heart disease Dizziness or fainting spells Bed wetting since age 12 X-ray or other radiation therapy Eye trouble Kidney stone or blood in urine Chemotherapy Hearing loss Sugar or albumin in urine Recurrent ear infections Sexually transmitted diseases Asbestos or toxic chemical exposure Chronic or frequent colds Recent gain or loss of weight Plate pin or rod in any bone Severe tooth or gum trouble Eating disorder anorexia bulimia etc. Loss of finger or toe Tuberculosis or positive TB test Bone joint or other deformity Pain or pressure in chest Easy fatigability Sinusitis Hay fever or allergic rhinitis Heart trouble Head injury Arthritis Rheumatism or Bursitis Asthma Thyroid trouble or goiter NSN 7540-00-181-8368 Previous edition not usable Epilepsy or seizure Been told to cut down or criticized for alcohol use Used illegal substances Used tobacco STANDARD FORM 93 REV. .