This document is a medical history form to be completed by household members. It asks about history of or treatment for medical conditions like tuberculosis, cancer, arthritis, heart/kidney issues, asthma, depression, alcoholism, seizures, headaches, and others. It also inquires about history of mental/emotional problems, medications, counseling, evaluations, disabilities, drug/alcohol treatment, and permission to release medical records. The purpose is to gather health information on household members.

1. HEALTH STATUS
(TO BE COMPLETED BY EACH HOUSEHOLD MEMBER)
NAME: DATE OF BIRTH:
MEDICAL HISTORY
Have you had a history of, or treatment for, any of the following?
NO YES NO YES NO YES
Tuberculosis Depression Alcoholism
Cancer Seizures Asthma
Severe Arthritis Heart Condition Chronic
Headaches
Chronic Kidney Mental/Emotional Chronic Fatigue
Condition Problems
Colitis Ulcers Insomnia
Eczema Hemophilia Allergies
Hayfever Diabetes Other:
_______________
Have you ever received treatment for mental problems? Yes or No
If yes, when?________________________________ From whom? ________________________
Have you taken medication for mental or emotional problems? Yes or No
Latest Revision 06/01/09 Page 1 of 3 file: CPA Policies/Forms/Parent Files/Medical History

2. When? Drugs Prescribed
____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Have you ever gone to counseling for emotional or family problems? Yes or No
If yes, describe:
HEALTH STATUS
Have you ever had a psychological evaluation or battery of psychological test? Yes or No
If so, when______________________________________________________________________
List all prescription medications being taken on a regular basis.
Medication Reason for Medication
_______________________________________________________________________________________
_______________________________________________________________________________________
Date of last visit to doctor and reason. _______________________________________________
______________________________________________________________________________
List all illness you have had in the past year.
___________________________________
___________________________________
___________________________________
Do you have any physical disability? ______ ______ If yes, when and what? _______________
NO YES
______________________________________________________________________________
Have you ever been treated for drug usage? ______ ______ If yes, when and where?
NO YES
Latest Revision 06/01/09 Page 2 of 3 file: CPA Policies/Forms/Parent Files/Medical History

3. Have you ever been treated for alcoholism? ______ ______ If yes, when and where?
NO YES
A statement may be needed from a physician, psychologist, or counselor concerning you and/or your
child’s past or current physical, mental, or emotional condition. Are you willing to give permission for
release of such information if necessary?
______ ______ __________________________________ ___________
NO YES Signature Date
Latest Revision 06/01/09 Page 3 of 3 file: CPA Policies/Forms/Parent Files/Medical History