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Patient Medical History
General Information
Full Name
*
DOB
*
E.g., 10/15/2019
Height
Feet
- None -
1
2
3
4
5
6
7
8
Inches
- None -
1
2
3
4
5
6
7
8
9
10
11
12
Weight
lbs
Referring Physician
Physician Name
*
Physician City
Pharmacy
Pharmacy Name
Pharmacy Location
Pharmacy Insurance
Currently Being Treated For:
(Please check all that apply)
AIDS/HIV
Anemia
Arthritis
Asthma
Blood Clots
Cancer
Chronic Pain
Claustrophobia
Diabetes
Dialysis
Fibromyalgia
Heart Problems
Hepatitis
High Blood Pressure
High Cholesterol
Infections
Kidney Problems
Lung Problems
Mental Health
Osteoperosis
Seizures
Sleep Apnea
Strokes/TIA
TB
Thyroid
Primary Physician For Above Problems
Have You Had Any of these Symptoms in the Last 6 Months?
(please check all that apply)
Abdominal Pain
Blackouts/Fainting
Bleeding
Chest Pain
Fevers
Hard of Hearing
Loss of Appetite
Loss of Vision
Mental Health Symptoms
Pain
Shortness of Breath
Swelling
Weight Loss
Other
Family History
Please check whether anyone in your immediate family has ever experienced any of the following:
Osteoarthritis
Mother
Father
Brother
Sister
Child
Osteoperosis
Mother
Father
Brother
Sister
Child
Diabetes
Mother
Father
Brother
Sister
Child
High Blood Pressure
Mother
Father
Brother
Sister
Child
Pain
Pain
Please describe the areas on your body where you feel pain. Please be specific, i.e. "back of left knee", "front right shoulder".
Pain Scale
*
- Select a value -
1 - No Pain
2
3
4
5
6
7
8
9
10 - Extreme Pain
If you are having pain, please select the intensity of your pain on a scale of 1-10. 1 being no pain and 10 being extreme pain.
Treatments
Please list the type of treatments have you tried in the past for your orthopaedic condition?
Examples: Injections, weight loss, physical therapy, NSAIDS (eg. Advil, Tylenol), pain medications, etc.
Medications
Please list all current medications including over-the-counter medications, vitamins and herbal supplements you take.
Medications
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Medication Name
Dosage / # Per Day
Reason for Taking
Please list all current medications including over-the-counter medications, vitamins and herbal supplements you take.
Allergies
Please list all allergies to medications, metals, latex, tape and dyes.
Allergies
Allergy to (drug, etc.)
Reaction (itching, cough, hives, etc.)
How was/is the reaction treated?
Allergy to (drug, etc.)
Reaction (itching, cough, hives, etc.)
How was/is the reaction treated?
Allergy to (drug, etc.)
Reaction (itching, cough, hives, etc.)
How was/is the reaction treated?
Allergy to (drug, etc.)
Reaction (itching, cough, hives, etc.)
How was/is the reaction treated?
Allergy to (drug, etc.)
Reaction (itching, cough, hives, etc.)
How was/is the reaction treated?
Allergy to (drug, etc.)
Reaction (itching, cough, hives, etc.)
How was/is the reaction treated?
Please list all allergies to medications, metals, latex, tape and dyes.
Surgery History
Surgical History
List type of operation and date.
Have you had any problems with anesthesia?
Anesthesia Issues
*
No
Yes
If yes, please explain:
Substance Use
Cigarette/Tobacco Use
List packs per day, length of use.
Alcohol Use
List type and frequency of use.
Other Substance Use
Employment Status
*
Employed
Unemployed
Disabled
Retired
Student
Patient/Authorized Signature
*
I attest to the best of my knowledge that the above health history including my current medications are accurate.
Date
*
E.g., 10/15/2019
Status
- None -
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