Medical History

Today’s Date October 23, 2004

Name Gonzalez Roberto	 Miguel
Address 4124 N Kiowa Colorado Springs, CO 80905
Home Phone 719-234-5567	 Work Phone 719-278-8819
Birth date June 16, 1978 Sex Male 
Birthplace Tucson, Arizona
Martial Status Single Employer U.S. Postal Service
Insurance Company Health One	Policy # 897522-C

Do you have or have you had any of the following?
Damaged heart valve? ___ yes _X__ no
Cardiovascular disease? ___ yes __X_ no
Allergies? _X__ yes ___ no
Sinus Trouble? _X__ yes ___ no
Diabetes? ___ yes _X__ no
Low/high blood pressure? ___ yes __X_ no
Stomach ulcer? ___ yes __X_ no
Kidney trouble? ___ yes __X_ no

List any allergic reactions to drugs: penicillin and aspirin

Where was the patient born?
1. Colorado Springs, CO
2. Tucson, AZ
3. Health One
4. U. S. Postal Service
Does Roberto have health insurance?
1. yes
2. no
To what is Roberto allergic?
1. penicillin and aspirin
2. only aspirin
3. only penicillin
4. ulcers
Does Roberto have sinus problems?
1. yes
2. no
What is the purpose of this form?
1. to record health information
2. to make a medical insurance claim
3. to apply for a job at the hospital
4. to cancel health insurance
Is Roberto married?
1. no
2. yes
Does Roberto have a stomach ulcer?
1. yes
2. no

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Medical History