* indicates a required field
    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

    Start typing and press Enter to search