Name: _________________________________Date: ______________Age: __________ PAST MEDICAL HISTORY YEAR ILLNESSES
________ ( ) Heart trouble (angina__) (heart attack ___) (Heart failure ___) (Heart murmur __) (valve
________ ( ) High blood pressure ________ ( ) Stroke ________ ( ) Ulcers (stomach ___) (duodenal___) (colon___) ________ ( ) Diabetes (high blood sugar) ________ ( ) Liver disease (hepatitis___) (A___) (B___) (Cirrhosis ___) Other______________________________ ________ ( ) Kidney disease (stones ___) (infections ___) other ____________ ________ ( ) Lung disease (emphysema ___)(TB___)(chronic bronchitis ___)(cancer___)
(frequent pneumonia___)(asthma___)Other_______________________
________ ( ) Blood disorders (anemia___) (leukemia ___) (bleeding tendency ___) Other _____________________________________________ ________ ( ) Eye disease (glaucoma___) Other_______________________ ________ ( ) Arthritis (degenerative___) (rheumatoid___) (gout ___)Other___________ ________ ( ) Cancer, Type ______________________________________ ________ ( ) Psychological difficulties (depression___) (psychosis ___) )Other________ ________ ( ) Other major illness_____________________________________________ ________ ( ) No major illnesses YEAR SURGERIES
________ ( ) Hysterectomy (total___) ( partial___) ________ ( ) Biopsy (result & type__________________________) ________ ( ) Fractures explain_________________________________________ ________ ( ) Other _________________________________________________
MAJOR INJURIES/ ACCIDENTES MAYORES ( ) Auto or cycle accidents:________________________________________________ ( ) NO MAJOR INJURIES HOSPITALIZATIONS:__________________________________________________
MEDICATIONS/MEDICINAS (Names & Dosages, if you have more please list on the back of the page.) ( ) ________________________________________________________________ ( ) ________________________________________________________________ ( ) ________________________________________________________________ ( ) ________________________________________________________________ ( ) Birth Control Pill __________________________________________________ ALLERGIES Describe Reaction: ( ) Penicillin (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
(rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__)
( ) Keflex (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__) ( ) Codeine (rash___) (breathing problems___) (required hospitalization___) (nausea/vomiting__) ( ) Other ________________________________________________________ ( ) None ________________________________________________________ FAMILY MEDICAL HISTORY/HISTORIA MEDICA FAMILIAR MOTHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____ ( ) Deceased / Cause:________________________ Age of death ________ FATHER: ( ) Alive & well ( ) Alive but suffers with:________________ Age____ ( ) Deceased / Cause:________________________ Age of death ________ SIBLINGS: ( ) Alive & well ( ) Alive but suffers with:________________ Age____ ( ) Deceased / Cause:________________________ Age of death ________ Members of my family: (brothers, sisters, grandparents, aunts, uncles) suffer from the following: ( ) Stroke
( ) Diabetes ( ) Back problems ( ) Heart trouble
SOCIAL HISTORY/HISTORIA SOCIAL 1. Married ___, Separated ___, Divorced ___, Widow-Widower____, Single______ No. of children at home ______ No. of children away ______ 2. I work as/ am retired from______________________________________________________ 3. I drink alcohol: None____ Daily____ Socially______ Beer_____ Wine_____ “Hard drinks”_______ I drink too much_______________________________ Others think I drink too much______ 4. I smoke: None____ Cigarettes_____ Pipe________ Cigars____
I smoke_____ packs______ a day, for_____ years.
Packs of runners in their spandex pants and balaclavas moving like a day-glow amoeba as they pound out the miles of their training regime. On the run, conversations go to intimate places, especially on those long three-hour tromps all over town: training tips, what to eat before a run, what to eat so you don’t get the runs while on a run, best flavours of Gatorade, how annoying a spouse was,
Example SBA Questions for Primary FRCA 1. A patient in hospital develops a tachycardia with a regular rate of 145 bpm and a blood pressure of 95/42 mm Hg. He denies chest pain, although he is acutely aware of his rapid heart rate. An ECG shows the duration of the QRS complex to be 0.10 s. The single most appropriate immediate treatment is: A. Adenosine 6mg B. Amiodarone 300mg
General Medical Information 
