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
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
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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