Form 93 – Fill Out and Use This PDF

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

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.

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.)

STANDARD FORM 93 (REV. 6-96) BACK