Orthopaedic Associates, Inc.
Medical History Form
Appointment Date: ___________________ With Dr. _____________________________ Chart #__________
Patient Name: ____________________________________ Age: ______ Sex: ( )F ( )M Height _____ Wt. ______
Please explain reason for this visit. Please list involved body parts, and comment on whether you have pain, numbness, weakness, swelling, stiffness, or other symptoms
________________________________________________________________________________________________
________________________________________________________________________________________________
How long ago did this start? ______________ Have you had a problem like this before? ( )Yes ( )No
Were you injured for this problem on the job? ( ) Yes ( ) No
What treatments have you tried thus far?
|
( ) medications |
( ) physical therapy |
( ) brace |
|
( ) cane/crutch |
( ) injections |
( ) chiropractic treatment |
( ) surgery for this same problem? Please list procedure, surgeon and date:____________________________________
Current Work Status: ( )Regular ( )Light Duty (how long? _______________________)
( )Not working due to this problem ( )Disabled ( )Retired ( )Student
When is the last date you worked at your regular job? ________________________________
Are you currently receiving or have applied for: Disability? ( )Yes ( )No
Workers Comp? ( )Yes ( )No Unemployment? ( )Yes ( )No
PAST MEDICAL HISTORY
Do you have, or have you ever had, any of the following? (Check all that apply)
|
( )Heart Disease |
( )Stroke |
( )Hepatitis/Jaundice |
|
( )High Blood Pressure |
( )Kidney Problems or Failure |
( )HIV/AIDS |
|
( )Diabetes
Controlled with ( )insulin
( )pills ( )diet |
( )Seizures |
( )Asthma/Emphysema |
|
( )High Cholesterol |
( )Cancer: where? |
( )Ulcer/Acid Reflux |
|
( )Blood Clot |
( )Depression |
( )Thyroid Disease |
|
( )Anemia or Bleeding Disorder |
( )Osteoporosis |
|
Surgeries (check all that apply, and list below those not outlined here):
( )Appendectomy ( )Tonsillectomy ( )Gallbladder ( )Hysterectomy ( )Cataracts ( )Hernia
Please list your current medications, both prescription and over the counter:
ALLERGIC TO ANY MEDICATIONS? ( )No ( )Yes List allergies: ___________________________________
FAMILY HISTORY
Has any blood relative ever had? (Check all that apply)
( )Asthma ( )Bleeding problem ( )Cancer; type ___________ ( )Diabetes ( )Hypertension ( )Heart disease ( )High cholesterol ( )Kidney disease ( )Stroke ( )Other_____________________________________________
SOCIAL HISTORY
Do you use tobacco? ( )No ( )Yes If yes, packs per day: _______ Informed of smoking risk? ( )
Alcohol use? ( )No ( )Yes If yes, how often? ( )Daily ( )Other: ______drinks/week
Marital Status: ( )M ( )S ( )D ( )W Education (Years/Degree):____________________
Occupation: _________________________________________ ( )Student
Employer: __________________________________________
REVIEW OF SYSTEMS
Have you had any of these symptoms? Please circle all that apply
|
System |
Symptoms |
|
|
Constitutional/General |
Fever, Weight gain, Weight loss, Change of appetite |
( )None |
|
Eyes |
Blurred vision, Double vision, Vision loss |
( )None |
|
ENT |
Deafness, Sinusitis, Hoarseness, Vertigo, Trouble swallowing |
( )None |
|
Cardiovascular |
Chest pain, Palpitations, Irreg. or Rapid heart beats, Murmur |
( )None |
|
Respiratory |
Shortness of breath, Wheezing, Chronic cough, Spitting up blood |
( )None |
|
Digestive |
Heartburn/ulcers, Nausea/vomiting, Blood in stool, Hepatitis/Liver disease, Constipation or Diarrhea |
( )None |
|
Urologic |
Pain with urination, Incontinence, Hesitancy, Bleeding |
( )None |
|
Gynecologic |
Breast masses, Pain, Discharge, Date of last exam: ___________ |
( )None |
|
Skin |
Rashes, Lesions that do not heal, Change in moles |
( )None |
|
Neurologic |
Seizures, Loss of balance/coordination, Paralysis, Weakness, Memory loss |
( )None |
|
Psychiatric |
Depression, Anxiety, Hallucinations, Sleep disturbances |
( )None |
|
Endocrine |
Excessive thirst, Excessive urination, Heat or cold intolerance |
( )None |
|
Blood/Lymphatics |
Anemia, Bleeding tendencies, Swollen nodes |
( )None |
|
Allergic/Immunologic |
Hives/itching, Eczema |
( )None |
|
Musculoskeletal |
Stiffness, Joint pain or deformity, muscle wasting, gout, rheumatoid arthritis |
( )None |
Please sign indicating that the information provided is accurate to the best of your knowledge:
_________________________________________________________________
Patient signature Date
_________________________________________________________________
Physician signature Date
