Dr. Cantrell Medical Information Sheet

Medical Information Sheet

Dr. Cantrell
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Date of Appointment *

Month Day Year
Date
Time of Appointment *

: Hour Minutes AM/PM Option
Home Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number
Please answer the following questions to the best of your ability.
What problems bring you to the clinic? *
Do you have pain

at night at rest with activity
What symptoms do you have? *
When did they start? *
Are you allergic to or had a reaction to any medications? *
Please list the medication & reaction
Are you allergic to any type of chicken products?
Are you allergic to latex?
Have you ever had swelling, itching, hives, or other symptoms after contact with a balloon?
Have you ever had swelling, itching, hives, or other symptoms after contact with rubber products?
Have you ever had swelling, itching, hives, or other symptoms after contact with latex products?
Are you allergic to bananas, avocados, kiwi fruits, or chestnuts?
Are you allergic to any type of shellfish?
Please check the boxes below if you have a history of the following: *

Breathing problems Heart problems Recent fever Blood pressure problems Diabetes Insulin Oral medication Diet Arthritis Mobility problems Wheelchair use Crutches/cane Walker Ulcers Weight changes Urinary problems Bowel problems Vision problems Hearing problems Recreational substance use Require a special diet Blood transfusion Seizures Cancer Are you pregnant? Menstrual changes
Do you smoke?
How often?
Do you drink alcoholic beverages?
How often do you consume alcohol? *

Daily Weekly Monthly Occasionally Never
If you answered yes to any of the above questions, please explain.
If you are under a doctor's care for any problems other than the one for which you are here, please explain.
List any past serious medical problems, including dates.
List any past major surgeries, including dates.
If you have ever had any problems with anesthesia, please explain.
Are you currently taking any medication?
Please list all medications you are taking on a daily basis.
Please list any family history problems.
What is your Gender? *

Male Female
Your age *
Your height *
Your weight *
Marital status *

Single Married Divorced Widowed
Which hand is your dominant hand? *

Right hand Left hand Both
Occupation *
What sports or recreational activities do you do?
What are your hobbies?
Who completed this form? *

Patient Spouse Parent Child
Have you or anyone in your family been treated by the doctor you are seeing today?
Please list their name and orthopedic problem
Signature *

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