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Name:*
MRN:
Date:*

Patient Medical History

Occupation:
Sex:
MaleFemale
Height:
Weight:
Referring Physician:
Age:
Date of birth:

Chief Complaint/History of Present Illness

In your own words, what is (are) your specific concern(s)?
Rate the pain (Please circle: 0= no pain; 10=most severe)
012345678910
What activites/medications help your condition?
What previous treatments have you had for this problem?
Have you had a fall in the last 12 months?
yesno
Have you had a DEXA scan?
yesno

Medical History:

Please check any of the following that you have had:

Diabetes: type 1 or 2Thyroid ProblemsHeart ProblemsBlood ClotsHigh Blood PressureStrokeSeizures
AsthmaTuburculosis (TB)Liver ProblemsElevated CholesterolKidney, Bladder or Prostate ProblemsStomach Ulcer or Reflux ProblemsDifficulty Opening Mouth
Muscle DisordersMental Health DisordersSkin DisordersSleep ApneaSevere/Migrane HeadachesArthritis RAArthritis OACancer (see the below)
Other serious health conditions:

Surgical History:

Please list any previous surgeries you have had:

Surgery

Date

Physician

Hospital

City/State

Current Medications:

Please list all medications you are currently taking:

Medication

Dosage (mg, mcg, etc.)

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

Allergies:

Are you allergic to latex?
YesNo
Are you allergic to any medications?
YesNo
If allergic to any medications, list medication and reaction:
List any other allergies:

Social History:

Do you use tobacco?
YesNo
Form of tobacco:
Frequency of use (eg., 2 packs per day)
Do you drink alcoholic beverages?
YesNo
Average # of drinks per week:
Do you have a history of substance abuse:
YesNo

Family History:

Has or does anyone in your family have any of the following?

Heart Trouble
yesno
Relationship
Diabetes
yesno
Relationship
Tuburculosis
yesno
Relationship
High Blood Pressure
yesno
Relationship
Pneumonia
yesno
Relationship
Cancer
yesno
Relationship
Sudden Death
yesno
Relationship
Arthritis
yesno
Relationship

Review of Systems

Musculoskeletal:

Do you have any chronic or itermittent back pain?
yesno
Do you have problems with other joints such as pain, swelling, stiffness or weakness?
yesno
If YES, please explain:

Skin:

Do you have any rashes, lesions, lumps or sores?
yesno
Do you have problems with any other joints such as pain, swelling, stiffness or weakness?
yesno
If YES, please explain:

Neurological:

Do you have history of seizures or other nervous system disorders requiring medication? If YES, please explain:
YesNo
If YES, please explain:
Do you have any previous history of stroke?
yesno
Do you have any problems with headaches or dizziness?
yesno

Psychiatric:

Do you have a drug or alcohol addiction?
yesno
Do you have any problems with depression?
yesno

Endocrine:

Do you have any problems with excessive thirst or intolerance to heat or cold?
yesno

Hemotology:

Do you have any problems with easy bleeding?
yesno
Do you have any problems with easy bruising?
yesno
Do you have any problems with anemia?
yesno
Have you ever had a blood clot?
yesno

Constitutional:

Have you had any recent coughs or colds?
yesno

Eyes:

Do you have any tearing, eye pain, pressure or change in vision?
yesno

Ear, Nose, & Throat:

Do you have any sore throats?
yesno
Do you have difficulty hearing?
yesno

Cardiovascular:

Do you have any chest or arm pain on exertion?
yesno
Do you have chronic cough either dry or with blood or sputum?
yesno

Gastrointestinal:

Do you have gastritis?
yesno
Do you have colitis?
yesno
Do you have diverticulitis?
yesno
Do you have hepatitis?
yesno

Other Considerations:

Do you have vision or hearing disabilities?
yesno
Please specify:
Do you have physical limitations?
yesno
Please specify:
Is there anything else we should know about you?

Patient Signature*
First Name
Middle Name
Last Name
Today's Date

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