Health History

    * indicates a required field
    Name:*
    MRN:
    Date:*
    Occupation:
    Sex:
    MaleFemale
    Height:
    Weight:
    Referring Physician:
    City/State of Referring Physician
    Age:
    Date of birth:
    In your own words, what is (are) your specific concern(s)?
    Affected Area:
    AnkleRightLeftBothPainInstability
    FootRightLeftBothPainInstability
    Fracture:
    Other:
    Did you sustain an injury?
    YesNo
    Date of injury
    Was it work related?
    YesNo
    If yes, what is your current work status?

    If no, during what activity?

    How bad is your pain the last 24 hours?

    At rest
    012345678910
    Daily activity
    012345678910
    Sporting activity
    012345678910
    What is worst pain experienced during day
    012345678910

    Have you had a fall in the last 12 months?
    yesno
    If yes, # of falls

    Present/Past Medical History:

    Please check all that apply:



    Orthopedic/Neurologic Surgeries, Fractures (last 10 years)

    None
    Joint Replacement

    Dates:
    Arthroscopy

    Dates:
    Spine Surgery
    Type:
    Dates:
    Fractures
    Type:
    Dates:
    Ankle/Foot Surgery
    Type:
    Dates:

    Other Past Surgeries

    None

    Other:
    Dates:

    Hospitalizations other than surgeries (last 10 years)

    None
    Date
    Purpose
    Date
    Purpose
    Date
    Purpose

    Current Medications

    (includes non-prescription products)

    Medication

    Dosage (mg, mcg, etc.)

    Frequency (times per day, as needed, etc.)


    Allergies:

    Are you allergic to any medications?
    yesno
    If allergic to any medications, list medication and reaction:

    Pertinent Family Medical History

    (cancer, heart, disease, hypertension, etc):


    Special Considerations

    None
    Tobacco use: YesNo
    Packs/day:
    Alcohol use: YesNo
    Drinks/week:
    Recreational Drug use: YesNo
    Type: Frequency:

    Activity Level

    Competitive athleteWell-trained/frequent sportsSedentary
    What would you like your physician/team to accomplish today?
    Accurate diagnosisMedicationSurgery plan if necessaryHealthy exercise plan (may include acupunture, massage, manipulation)Disability info
    Other:

    Patient Signature*
    First Name
    Middle Name
    Last Name
    Today's Date
    Parent/Guardian Signature*
    First Name
    Middle Name
    Last Name
    Today's Date

    Start typing and press Enter to search