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

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