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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.