Standard Form 93 PDF Details

The Standard 93 form serves as a comprehensive medical record, meticulously designed to capture an individual's health history, current health status, and various medical details crucial for official and medically-confidential purposes. From basic information such as the patient's name and identification number to more detailed inquiries about past and present health conditions, allergies, medications, and even surgical history, the form ensures a thorough medical evaluation. It also addresses the patient's occupational history, lifestyle choices including the use of tobacco and alcohol, and responses to previous employment or military service rejections due to medical reasons. For women, specific health queries related to female disorders, menstrual patterns, and routine check-ups like mammograms and pap smears are included to provide a gender-specific health overview. Furthermore, the form delves into mental health, previous hospitalizations, and consultations with medical practitioners, alongside a detailed account of immunizations received. By certifying the accuracy of the information provided, individuals acknowledge the form's importance in the processing of applications for employment or service, thereby underlining the Standard 93 form's role as a critical tool in maintaining the health and safety of individuals within various official capacities.

QuestionAnswer
Form NameStandard Form 93
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesstandard form 93 rev 6 96, FIRMR, 24a, sf 93 report of medical history

Form Preview Example

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 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 coughing

 

 

 

Palpitation or pounding heart

 

 

 

 

 

 

or elbow

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 (include 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,

 

 

 

 

Frequent or severe headaches

 

 

 

Frequent or painful urination

 

 

 

 

 

 

cancer, stroke or heart disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 disease

 

 

 

 

 

 

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 7540-00-181-8638

 

 

 

 

 

 

 

 

 

 

 

STANDARD FORM 93 (REV. 6/96) (EG)

Previous edition not usable

 

 

 

 

 

 

 

 

 

 

 

Prescribed by ICMR/GSA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRMR (41 CFR) 201-9.202-1

 

 

Designed using Perform Pro, WHS/DIOR, Apr 97

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 significant 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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1. To begin with, while filling out the RFD, beging with the part containing next blanks:

Filling in section 1 in 26a

2. Right after performing the last section, go to the subsequent stage and fill in all required details in all these blank fields - PATIENTS OCCUPATION, ARE YOU Check one, RIGHT HANDED, PASTCURRENT MEDICAL HISTORY, LEFT HANDED, CHECK EACH ITEM, YES, DONT KNOW, CHECK EACH ITEM, YES, DONT KNOW, CHECK EACH ITEM, YES, DONT KNOW, and Household contact with anyone with.

DONT KNOW, RIGHT HANDED, and ARE YOU Check one of 26a

3. Completing Suicide attempt or plans, NSN Previous edition not usable, Jaundice or hepatitis Broken bones, Eating disorder anorexia bulimia, Arthritis Rheumatism or Bursitis, Thyroid trouble or goiter, Plate pin or rod in any bone Easy, Been told to cut down or, Used illegal substances Used, and STANDARD FORM REV EG Prescribed is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Guidelines on how to complete 26a step 3

4. This specific section comes next with the next few blank fields to focus on: CHECK EACH ITEM, Treated for a female disorder, YES, DONT KNOW, DATE OF LAST MENSTRUAL PERIOD, DATE OF LAST PAP SMEAR DATE OF, GRAM, CHECK EACH ITEM IF YES EXPLAIN IN, YES, Have you been refused employment, a Sensitivity to chemicals dust, Have you ever been treated for a, Have you ever been denied life, Have you had or have you been, and Have you ever been a patient in.

Find out how to complete 26a step 4

5. This last stage to finish this document is crucial. Make sure to fill in the necessary blank fields, which includes Have you ever been discharged, Have you ever been arrested or, Have you ever been diagnosed with, LIST ALL IMMUNIZATIONS RECEIVED, I certify that I have reviewed the, b SIGNATURE, c DATE, NOTE HAND TO THE DOCTOR OR NURSE, a TYPED OR PRINTED NAME OF, b SIGNATURE, c DATE, and STANDARD FORM REV BACK, prior to using the file. Or else, it could end up in an incomplete and possibly invalid paper!

26a writing process detailed (step 5)

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