Name: Date of Birth: / / Age: Date: /

Patient Information Sheet

Today’s

Name: Date of Birth: / / Age: Date: / /

Height: Weight: R L Handed Male Female Are you or could you be pregnant? Y N

Employer: Occupation:

Reason for today’s visit :

Who is your primary care physician?

Date of injury or onset of problem: _____/______/______Area of body involved:______

Left Right Is this work related? Yes No Workmen’s comp claim filed? No Yes

Have X-Rays been taken No Yes Where______When?______

Previous Similar Complaint:NoYes Have you returned to work NoYes When?______

ALLERGIES: Are you allergic to ANY drugs NO Yes list all DRUG ALLERGIES including reactions

Are you allergic to? DRUG: REACTION:

Eggs No Yes*

Iodine No Yes*

Latex No Yes*

Nuts No Yes*

Penicillin No Yes*

Sulfa No Yes*

Tape No Yes*

______

______

______

______

(*) Note reactions to all yes answers ______

CURRENT MEDICATIONS: Do you take any medication? No Yes List all, include Over the Counter Meds, Herbs and Vitamins

Drug Name/Strength Dose Prescribing Physician Drug Name/Strength Dose Prescribing Physician

______

______

______

______

Have you ever had a cortisone injection No Yes Area injected:______

SURGICAL HISTORY: Have you undergone any surgical procedures? No Yes List all surgeries, include left or right when indicated:

Year Surgery Year Surgery Year Surgery

______

______

______

ANESTHESIA: Have you ever had problems with anesthesia? No Yes Explain

______

Health History page 1 of 3

Patient Name: ______Date:____/____/____

MEDICAL HISTORY: List all current medical conditions under treatment None

Condition Treatment Treating Physician Condition Treatment Treating Physician

______

______

______

______

REVIEW OF SYSTEMS: Are you currently having or have you ever had problems with:

No YesNo Yes No Yes

Allergies (Hay fever)Fibromyalgia Neurological Problems

AnemiaGallstones Numbness/tingling

ArthritisGlaucoma Old Fractures

AsthmaGout Osteoarthritis

BalanceHeart Disease Osteomyelitis

Birth DefectHepatitis/Jaundice Osteoporosis

Blackout/FaintingHigh Blood Pressure Polio

BladderHigh Cholesterol Rheumatic Fever

BleedingHIV/AIDS Rheumatoid Arthritis

Blood ClotsJoint Swelling Shingles

CancerKidney Stones Sickle Cell

Chest PainLiver Problems Stomach/Ulcers

DepressionLung Problems Stroke

DiabetesMental Illness Thyroid Disease

EmphysemaMigraine Headaches Tuberculosis (TB)

Epilepsy or SeizuresMultiple Sclerosis Poor Wound Healing

Other

DESCRIBE ALL YES RESPONSES:

______

FAMILY HISTORY: None Mother Father Siblings None Mother Father Siblings

Asthma Mental Illness

Bleeding Disorders Osteoarthritis

Cancer Rheumatoid Arthritis

Diabetes Seizures

DVT (Blood Clots) Sickle Cell

Heart Disease Stroke

High Blood Pressure Thyroid Disease

Kidney Disease Tuberculosis

Other

Give Details to “Other” or any positive responses

______

Health History page 2 of 3

Patient Name:______Date ____/____/______

SOCIALHISTORY:

Do you smoke tobacco NoYes ______Packs per day for _____Years

Did you quit smoking tobacco NoYes When______Previously smoked___packs per day for___ yrs

Do you chew tobacco NoYes How often?______

Do you drink alcohol NoYes How much? How often? ______

Do you live alone NoYes Do you have children?No Yes How Many? ______

Do you use walking aids NoYes Cane Crutches Walker Other______

Have you ever abused drugs or alcohol?NoYes If “Yes” Explain ______

______

Do you exerciseNeverRarelyWeeklyDailyType______

Patient

Signature:______Date______Update______by______

Reviewed by: ______Date______Update______by______

MD Signature______Date______Update______by______

Reviewed by / Date / Reviewed by / Date / Reviewed by / Date

Health History page 3 of 3