Patient Medical History
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Physician Name
*
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
Medical & Surgical History
Please indicate if the patient has had any of the following.
Medical disorders:
AIDS/HIV
Alcoholism
Alzheimer's
Anemia
Rheumatoid Arthritis
Asthma
Blood Clot (Leg)
Blood Clot (Lung)
Blood Thinners
Cancer (Breast)
Cancer (Lung)
Cancer (Prostate)
COPD
Depression
Diabetes
Drug Abuse
Gout
Heart Attack
High Blood Pressure
Hepatitis
Kidney Disease
Osteoarthritis
Seizures
Sleep Apnea
Stroke
Ulcers, Bleeding
Surgical history:
Cardiac (Heart)
Carpal Tunnel (Left Wrist)
Carpal Tunnel (Right Wrist)
Arthroscopy (Left Elbow)
Arthroscopy (Right Elbow)
Arthroscopy (Left Shoulder)
Arthroscopy (Right Shoulder)
Arthroscopy (Left Ankle)
Arthroscopy (Right Ankle)
Arthroscopy (Left Knee)
Arthroscopy (Right Knee)
Arthroscopy (Left Hip)
Arthroscopy (Right Hip)
Left Hip Replacement
Right Hip Replacement
Left Knee Replacement
Right Knee Replacement
Spinal Fusion
Laminectomy
Fracture Surgery
Family History History
Please indicate if the patient's family members have had any of the following.
Patient's Father:
AIDS/HIV
Anemia
Rheumatoid Arthritis
Blood Clot (Leg)
Blood Clot (Lung)
Cancer (Breast)
Cancer (Lung)
Cancer (Prostate)
Coronary Artery Disease
Diabetes
Gout
Heart Attack
Hemophilia
Hypertension
Kidney Disease
Liver Disease
Muscle Disease
Osteoporosis
Patient's Mother:
AIDS/HIV
Anemia
Rheumatoid Arthritis
Blood Clot (Leg)
Blood Clot (Lung)
Cancer (Breast)
Cancer (Lung)
Cancer (Prostate)
Coronary Artery Disease
Diabetes
Gout
Heart Attack
Hemophilia
Hypertension
Kidney Disease
Liver Disease
Muscle Disease
Osteoporosis
Patient's Siblings:
AIDS/HIV
Anemia
Rheumatoid Arthritis
Blood Clot (Leg)
Blood Clot (Lung)
Cancer (Breast)
Cancer (Lung)
Cancer (Prostate)
Coronary Artery Disease
Diabetes
Gout
Heart Attack
Hemophilia
Hypertension
Kidney Disease
Liver Disease
Muscle Disease
Osteoporosis
Review of Systems
Please indicate if the patient has any of the following.
Constitutional:
Weight Loss/Gain
Weakness
Fatingue
Fever
Cardiovascular:
High Blood Pressure
Chest Pain
Rheumatic Fever
Palpitations
Has Pacemaker
Musculoskeletal:
Joint Pain
Arthritis
Muscular Weakness
Stiffness
Muscular Pain
Musculoskeletal:
Joint Pain
Arthritis
Muscular Weakness
Stiffness
Muscular Pain
Eyes:
Glasses or Contacts
Blurred Vision
Glaucoma
Cataracts
Excessive Tearing
Skin:
Rashes
Sores
Lumps
Dryness
Itching
Blood or Lymph:
Anemia
Easy Bruising
Easy Bleeding
Swollen Glands
Ear Nose Mouth Throat:
Ears Ringing
Earaches
Hearing Aid
Frequent Colds
Nasal Discharge
Hay Fever
Nosebleeds
Dentures
Bleeding Gums
Frequent Sore Throats
Neurological:
Headache
Dizziness
Seizures
Loss of Sensation
Vertigo
Gastrointestinal:
Heart Burn
Rectal Bleeding
Abdominal Pain
Gallbladder Trouble
Hepatititis
Respiratory:
Shortness of Breath
Cough
Wheezing
Asthma
Bronchitis
Genitourinary:
Blood in Urine
Urinary Infections
Kidney Stones
Burning Urination
Sexual Disease
Endocrine:
Thyroid Trouble
Excessive Sweating
Excessive Thirst
Immunologic:
Reactions to Drugs
Skin Rashes
Reactions to Foods
Psychological:
Nervousness
Depression
Mood Changes
Social History
Do you use tobacco?
*
Yes
No
Former User
Do you use alcohol?
*
Yes
No
Do you use caffeine?
*
Yes
No
Do you use illicit drugs?
*
Yes
No
Which hand is your dominant hand?
*
Right
Left
Either
Could you be preganant?
Yes
No
Allergies to following medications or substances?
No Known Allergies
Amoxil
Ampicillin
Aspirin
Bactrim
Ceftin
Cefzil
Codeines
Depakene
Dilantin
Insulin
Iodine/Shellfish
Keflex
Lamictal
Lidocaine
Novacaine
Pediazole
Penicillin
Sulpha Drugs
Suprax
Septra
Tegretol
Vantin
Other allergies:
Latex
IVP/X-Ray Dye
Metal
Egg/Avian (Bird)
Please list any other allergies
Submit
Should be Empty: