Patient Medical History

General Information
E.g., 10/15/2019

Height

lbs
Referring Physician
Pharmacy
Currently Being Treated For:
(Please check all that apply)
Have You Had Any of these Symptoms in the Last 6 Months?
(please check all that apply)
Family History
Please check whether anyone in your immediate family has ever experienced any of the following:
Pain
Please describe the areas on your body where you feel pain. Please be specific, i.e. "back of left knee", "front right shoulder".
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
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.
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.
Please list all allergies to medications, metals, latex, tape and dyes.
Surgery History
List type of operation and date.
Have you had any problems with anesthesia?
Substance Use
List packs per day, length of use.
List type and frequency of use.
I attest to the best of my knowledge that the above health history including my current medications are accurate.
E.g., 10/15/2019