Dr. Giesler Medical History
Name
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First Name
Middle Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Date of Appointment
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Month
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Day
Year
Date
Time of Appointment
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Hour
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10
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30
40
50
Minutes
AM
PM
AM/PM Option
Referring physician
If any
Age
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Gender
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Male
Female
Height
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Weight
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Chief Complaint
Why are you seeing the doctor today?
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When did your symptoms start?
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Are you in pain?
Are you in pain at night?
How many minutes can you stand?
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How many minutes can you sit?
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How many minutes can you walk?
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List any treatment, medications, tests, or x-rays you have had for this problem
Is the current problem the result of an accident?
Date of injury
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Month
-
Day
Year
Date
Please explain the accident
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Have you had an MRI or CT scan?
Where was it done?
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Previous Surgeries
Have you had any previous surgeries?
Please list your previous surgeries
Medical Problems
Please check all that apply
Do you have diabetes?
Which type?
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Date diagnosed
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Month
-
Day
Year
Date
Do you or did you previously have cancer?
What type?
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Date diagnosed
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-
Month
-
Day
Year
Date
Active or in remission?
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Please list ALL other medical problems
Medications
Do you currently take any medications, including anti-inflammatories?
Please list your medications, including anti-inflammatories
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Allergies
Do you have any allergies?
Please list all known allergies
*
Social & Family History
Occupation
*
Where do you live?
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With whom do you live?
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Are you left or right handed?
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Left
Right
Either
Do you smoke?
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When did you quit?
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How many years do you/did you smoke?
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Packs per day?
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Do you drink alcohol?
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Do you have a history of substance/drug abuse?
Please explain
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Does your family have a history of heart problems?
Whom?
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Does your family have a history of lung problems?
Whom?
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Does your family have a history of arthritis?
Whom?
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Does your family have a history of blood clots?
Whom?
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Does your family have a history of cancer?
Whom?
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Please list all other family histories
Review of Systems
Have you had any of the following?
*
Please explain
*
Have you had any of the following?
*
Please explain
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Have you had any of the following?
*
Please explain
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Have you had any of the following?
*
Please explain
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Have you had any of the following?
*
Please explain
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Have you had any of the following?
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Please explain
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Have you had any of the following?
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Please explain
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Have you had any of the following?
*
Please explain
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Have you had any of the following?
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Please explain
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Have you had any of the following?
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Please explain
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Have you had any of the following?
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Please explain
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Have you had any of the following?
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Please explain
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Have you had any of the following?
*
Please explain
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Have you had any of the following?
*
Please explain
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Please describe any other problems the doctor should know about
Submit
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