PERSONAL HISTORY. In order to understand our clients’ background, and to assist in establishing the most suitable structure and banking arrangements (if required), information regarding our clients’ work experience and qualifications is likely to be of considerable assistance, together with a clear understanding of our clients’ wealth financial circumstances both past and present.
PERSONAL HISTORY. The Employee represents and warrants to the Employer that there is no scandal, whether or not involving a criminal conviction, in his/her past which if made public during his/her employment with the Employer would tend to harm the reputation of the Employer, whether among the public at large or among the clergy, employees or volunteer staff of the Employee.
PERSONAL HISTORY. 1. Have you, individually, as a partner, joint venturer or as an officer of a corporation had a bond or surety canceled or forfeited within the last ten (10) years? Yes. Provide information below. No Bond Company Name Bond Date Bond Amount Explain the reason for each cancellation or forfeiture.
PERSONAL HISTORY. A. Does Participant have allergies to any medicines, foods, bites and stings, etc? O yes O no If “yes”, please list:
PERSONAL HISTORY. Do you ever have any injuries, difficulties or problems during a high intensity exercise? If so, please Specify _ _.
PERSONAL HISTORY. Have you had any major injuries or accidents? ❑ No ❑ Yes If yes, please list with dates: Have you had any major illness, surgery or hospitalizations? ❑ No ❑ Yes If yes, please list with dates: Are you pregnant or could you be pregnant? ❑ No ❑ Yes If yes, how many months? Indicate whether you have had of the following experiences. Use a “C” for CURRENT if it happened in the last three months or a “P” for PAST if it happened in the past. Digestive System: Abdominal pain Belching Constipation Diarrhea Food Cravings Gall stone Gas or Bloating GERD’s or Heartburn Hemorrhoids Hepatitis IBS Nausea Poor Appetite Ulcers Other: Number of bowel movements daily? Are they? ❑ Loose ❑ Normal ❑ Hard ❑ Incomplete Nervous & Endocrine System: Anxiety Brain fog / Cloudy thinking Depression Difficulty concentrating Fatigue Headaches Hot flashes Hormonal imbalance High Stress Irritability Mental illness Mood swings Numbness or tingling Poor sleep Poor memory Racing thoughts Thyroid dysfunction Other: Indicate whether you have had of the following experiences. Use a “C” for CURRENT if it happened in the last three months or a “P” for PAST if it happened in the past. Immune: Allergies Auto-Immune condition Cancer Chemical sensitivities Chronic infection Hives Herpes Fevers Frequent colds or infection Swollen glands Other: Musculoskeletal:
PERSONAL HISTORY. Does child walk well? Yes No Run? Yes No Is your child a good climber? Does your child fall easily? Talking? Yes No In phrases? Yes_ _No In sentences? Yes No Does your child speak any other language? If yes, which HEALTH HISTORY: Physical Disabilities? Yes No Serious Illnesses? Yes No Known Allergies? Yes No Other Conditions or Limitations Is your child toilet trained? Yes No In the process of being trained? Yes No If yes, are you using a potty chair ? Toilet seat ? Does your child have frequent toilet accidents? Yes No How does your child react to accidents? Does your child let you know when he/she needs to use the toilet? Defecate word Vomit word Urinate word
PERSONAL HISTORY. Surgery: □ Gall Bladder □ Appendectomy □ Hiatal Hernia □ Inguinal Hernia □ Colon Resection □ Hysterectomy □ Gastric Bypass Other surgeries not listed/ dates Please describe any previous problems with Anesthesia Medical Problems: □ Diabetes Mellitus □ Hypertension □ Hyperlipidemia □ Migraine Headaches Other SYSTEMS REVIEW (please check those that apply to you): Digestive System □ Difficulty in swallowing □ Change in appetite □ Heartburn/esophageal reflux □ Nausea/vomiting □ Abdominal pain □ Bloating/belching/gaseousness Florida Medical Clinic Page 1 Digestive System (continued) □ Hemorrhoids □ Constipation □ Indigestion □ Diarrhea/ loose stools □ Black stools □ Gastrointestinal bleeding □ Rectal bleeding □ Change in bowel habits □ Irritable Bowel Syndrome □ Crohn's Disease/Ulcerative Colitis □ Gallstones/gallbladder disease □ Hepatitis/liver disease Ear, Nose, Throat □ Sinus pain □ Nose bleeds □ Hoarseness □ Hearing loss □ Ear pain/ringing Cardiology □ Chest pain or pressure □ Palpitations □ Pacemaker/Defibrillator □ History of heart attack □ Mitral Valve Prolapse or Murmur □ Artificial Heart Valve □ Hypertension/high blood pressure Pulmonary/ Respiratory □ Shortness of Breath □ Loss of breath on exertion □ Asthma/wheezing/coughing Genitourinary Are you pregnant? Date of last period? □ Recent/frequent Urinary Tract Inf. □ Blood in urine □ Burning with urination □ Urine incontinence □ History of kidney stones □ Genital bleeding/discharge Musculoskeletal □ Joint pain/ arthritis □ Back pain □ Problems with walking Lymphatic/Hematology □ Enlarged nodes/ swollen glands □ Anemia □ Bleeding problems Allergy/Immunology □ HIV/AIDS □ Blood transfusions Dermatological/ Skin □ Dermatitis or rash □ Itching □ Psoriasis Endocrine □ Diabetes □ Thyroid problem □ Hormonal problem □ Enlarged nodes/ swollen glands □ Anemia □ Bleeding problems Neurological □ Headaches □ Seizure disorder □ Stroke □ Tingling or numbness □ Dizziness Psychiatric □ Anxiety □ Depression □ Insomnia □ Memory loss □ Past evaluation and treatment OTHER? Obstetric History (Females): Number of pregnancies? Deliveries? Number of children? Florida Medical Clinic Page 2
PERSONAL HISTORY. As a member of the community at Summit Pacific College and potentially a credential holder of the Pentecostal Assemblies of Canada (PAOC), students need to be willing to comply with lifestyle commitments belonging to the community, which involve abstention from alcohol, tobacco, non-medical drugs, occultic activity and separation from all suggestion of immoral or unethical behavior. As Summit Pacific College is the educational arm of the PAOC we affirm lifestyle values that are consistent with credentialing responsibilities. Have you been involved with any of the above mentioned in either the past or present?
PERSONAL HISTORY. In answering each of the questions, select the appropriate box next to each question. For each “YES” answer, a separate, signed statement giving full details, including date(s), location(s), action(s), organization(s) or parties involved and specific reason(s) must be included with the application/proctection agreement . Read the definitions listed below before completing the personal history questions. “Ability to practice within your profession with reasonable skill and safety” means ALL of the following: o cognitive capacity, o ability to communicate with patients and other health care providers, o capability to perform health care services within your profession. “Medical condition” means any physiological, mental, or psychological condition, impairment, or disorder, including drug addiction and alcoholism.
