Form 93 PDF Details

In the realm of medical documentation and evaluation, the Standard Form 93, revised in June 1996, plays a crucial role by offering a comprehensive overview of an individual's medical history and current health condition. Serving both official and medically-confidential purposes, this form ensures that sensitive health information is kept secure and only shared with authorized personnel. It collects detailed data including the patient's name, identification number, and contact information, alongside their examination details such as the purpose, present health status, and ongoing medications. The depth of the form extends to cover allergies, vital statistics like height and weight, and an exhaustive list of medical conditions to be checked off, indicating their presence or absence in the patient's history. Additionally, the form is attentive to lifestyle aspects, encompassing occupation, handedness, and even habits such as alcohol and tobacco use. Its thorough evaluation extends to mental health and previous medical treatments, including surgeries and hospitalizations, ensuring a holistic view of the patient's health. For females, there's a specific section exploring gynecological health. Importantly, the document doesn't just compile a list of health-related inquiries; it actively invites patients to disclose any past rejections from employment or insurances tied to medical reasons, aiming to provide a full picture that supports informed medical and administrative decisions. Its signature and certification section emphasizes the accuracy and honesty of the provided information, underpinning the critical legal and ethical responsibility of all parties involved in the form's completion and usage.

QuestionAnswer
Form NameForm 93
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesreport medical history, form report medical pdf, medical record report, sf 93

Form Preview Example

(REV. 6-96)

NO. OF ATTACHED SHEETS:

DATE OF EXAM

MEDICAL RECORD

REPORT OF MEDICAL HISTORY

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

4b. CITY

4c. STATE

4d. ZIP CODE

6. PURPOSE OF EXAMINATION

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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

d. HEIGHT

 

 

e. WEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. PATIENT'S OCCUPATION

 

 

 

 

 

9. ARE YOU (Check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RIGHT HANDED

 

 

 

LEFT HANDED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. PAST/CURRENT MEDICAL HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHECK EACH ITEM

YES

NO

DON'T

CHECK EACH ITEM

YES

NO

DON'T

CHECK EACH ITEM

YES

NO

DON'T

KNOW

KNOW

KNOW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Household contact with anyone

 

 

 

 

Shortness of breath

 

 

 

Bone, joint or other deformity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

with tuberculosis

 

 

 

 

Pain or pressure in chest

 

 

 

Loss of finger or toe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tuberculosis or positive TB test

 

 

 

 

Chronic cough

 

 

 

Painful or "trick" shoulder

 

 

 

Blood in sputum or when

 

 

 

 

Palpitation or pounding heart

 

 

 

or elbow

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

coughing

 

 

 

 

Heart trouble

 

 

 

Recurrent back pain or any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Excessive bleeding after injury or

 

 

 

 

High or low blood pressure

 

 

 

back injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

dental work

 

 

 

 

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

 

 

 

Paralysis (including infantile)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eye surgery to correct vision

 

 

 

 

gallstones

 

 

 

Epilepsy or seizure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

Parent/sibling with diabetes,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

cancer, stroke or heart disease

 

 

 

Frequent or severe headaches

 

 

 

 

Frequent or painful urination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

Asbestos or toxic chemical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recurrent ear infections

 

 

 

 

Sexually transmitted diseases

 

 

 

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,

 

 

 

Easy fatigability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sinusitis

 

 

 

 

etc.)

 

 

 

Been told to cut down or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hay fever or allergic rhinitis

 

 

 

 

Arthritis, Rheumatism, or

 

 

 

criticized for alcohol use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Head injury

 

 

 

 

Bursitis

 

 

 

Used illegal substances

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asthma

 

 

 

 

Thyroid trouble or goiter

 

 

 

Used tobacco

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NSN 7540-00-181-8368

STANDARD FORM 93

Previous edition not usable

Prescribed by ICMR/GSA

 

FIRMR (41 CFR) 201-9.202-1

11. FEMALES ONLY

CHECK EACH ITEM

YES

NO

DON'T

DATE OF LAST MENSTRUAL

DATE OF LAST PAP SMEAR

DATE OF LAST MAMMO-

KNOW

PERIOD

 

GRAM

 

 

 

 

 

 

 

 

 

 

 

Treated for a female disorder

 

 

 

 

 

 

 

 

 

 

 

 

 

Change in menstrual pattern

 

 

 

 

 

 

 

 

 

 

 

 

 

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

ITEM

YES NO

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.)

23.LIST ALL IMMUNIZATIONS RECEIVED

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.

24a. TYPED OR PRINTED NAME OF EXAMINEE

24b. SIGNATURE

24c. DATE

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

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.)

26a. TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER

26b. SIGNATURE

26c. DATE

STANDARD FORM 93 (REV. 6-96) BACK

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