CITY OF FRANKLIN EMPLOYEE MEDICAL HISTORY FORM
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Date:

 

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First Name

 

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Last Name:

 

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Age:

 

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Date of Birth: 

 

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Sex:

Male
Female
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Primary Care Doctor:

 

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CURRENT AND PAST HEALTH HISTORY:

 
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Are you in good health at the present time to the best of your knowledge?

Yes
No
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Do you have or have you ever had high blood pressure?  If yes, indiate when.

Yes
No
  • Comment:

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Do you have or have you ever had high blood sugars (diabetes)?  If yes, indicate when.

Yes
No
  • Comment:

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Do you have or have you ever had elevated lipids or cholesterol?  If yes, indicate when.

Yes
No
  • Comment:

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List all of your medications with doses related to high blood pressure, elevated cholesterol, diabetes:

 

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Have you ever had heart problems?  If yes, indicate when and the date of your last heart testing.

Yes
No
  • Comment:

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Do you have a personal or family history of colon cancer or colon polyps?  If yes, please state who has this history and when it occurred.

Yes
No
  • Comment:

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Do you have a personal or family history of breast cancer?  If yes, please state who had breast cancer and when it occurred?

Yes
No
  • Comment:

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Please list any other medical problems

 

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Please list any sugeries you may have had

 

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Do you use alcohol?  If yes, what amount and what frequency?

Yes
No
  • Comment:

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Do you use tobacco?  If yes, what type, amount and frequency?

Yes
No
  • Comment:

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Do you snore loudly?

Yes
No
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Do you often feel tired, fatigued, or sleepy during daytime?

Yes
No
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Has anyone observed you stop breathing during your sleep?

Yes
No
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Is your neck circumference greater than 16 inches?

Yes
No

SCREENING HISTORY:

 
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Have you had a colonoscopy?  If yes, when?

Yes
No
  • Comment:

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Have you had a mamogram?  If yes, when was your last mammogram?

Yes
No
N/A
  • Comment:

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Have you had a pap test?  If yes, when was your last pap test?

Yes
No
N/A
  • Comment:

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Have you had a prostate PSA exam?  If yes, when was your last prostate PSA exam?

Yes
No
N/A
  • Comment:

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EMPLOYEE LIFESTYLE EVALUATION

 
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In the last month I:

 Always Usually Often Seldom Never 
Started eating when moderately hungry
Ate healthy foods that satisfied my taste and hunger
Ate slowly and chewed my food well
Enjoyed each bite and stopped eating when moderately full
Planned and prepared or helped to prepare my meals
Ate more meals at home
Away from home, ate at places with healthy food choices
Ate at least 3 regularly scheduled meals per day
Avoided/limited unplanned eating/snacking
Drank at least 50 oz. of water each day
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In the past month I:

 Always Usually Often Seldom Never 
Ate mostly healthy foods (high protein, low fat, low sugar)
Avoided/limited caffeine, carbonation, and alcohol
Took recommended vitamins
Kept a food and activity journal
Engaged in at least 1/2 hour of planned exercise
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In the past month I:

 Always Usually Often Seldom Never 
Managed stress without extra eating
Managed emotions without extra eating
Limited/reduced TV and recreational computer time
Felt in control of my lifestyle
Attended to my physical needs
Attended to my spiritual needs
Attended to my social needs
Accomplished something I feel good about