ORTHOPAEDIC SURGERY
Risser Orthopaedic Group
A Medical Corporation Donald J. Norquist, M.D.
Charles F. Prickett, M.D.
Daniel R. Laster, M.D
MEDICAL HISTORY QUESTIONNAIRE
NAME DATE
AGE HEIGHT WEIGHT
1. What condition or symptoms are you being seen for at this time?
2. Date of onset?
3. Describe your pain ...... None Mild Moderate Severe
4. Did you see a physician? ...... yes no
Were you treated in an emergency room? ...... yes no
Have you had x-rays taken? ...... yes no
Is this injury work related? ...... yes no
5. Are you currently under treatment by a physician for medical reasons? If “yes” please list. . . yes no
Condition Physician Address
6. Are you currently taking any medications? ...... yes no
If “yes” please list with the dosage.
7. Do you have any allergies? ...... yes no
If “yes” please list.
8. Have you ever had any surgeries? ...... yes no
If “yes” please list.
Description Year Name of Physician
9. Have you ever had a serious illness or injury? ...... yes no
If “yes” please list.
10. Name of personal physician
PLEASE CHECK (ü) either yes or no for each item, except where it applies to only male or female. If “yes”, please explain below.
YES NO YES NO
Asthma……………………… Hepatitis…………………….
Abnormal EKG………….. Heart problems………….
Angina………………………. High blood pressure…….
Anemia……………………… Kidney infections……….
Arthritis……………………… Kidney stones……………
Blindness, either eye… Liver disease…………….
Cancer……………………… Malaria………………………
Cataracts…………………… Measles……………………..
Chronic bronchitis………. Mumps………………………
Colon or bowel trouble. Phlebitis…………………….
Deafness…………………… Polio…………………………
Diabetes…………………….. Poor blood clotting………
Dislocations……………… Rheumatic fever…………
Emphysema……………… Skin disease……………….
Fractures…………………. Stomach ulcer……………
Gallstones………………… Stroke……………………….
Glaucoma………………… Tuberculosis……………….
Gout………………………….. Tumor, benign…………….
Headaches………………..
MEN: Prostate problems? (If yes, please explain below) ...... yes no
WOMEN: Age menstrual period started
Age menstrual period stopped
Irregular or abnormal periods ...... yes no
*PLEASE EXPLAIN:
Do you smoke or have you been a smoker? ...... yes no
If yes, amount per day
Have you ever been addicted to alcohol? ...... yes no
Are you on a special diet or diet restrictions? ...... yes no
If “yes”, please explain:
FAMILY HISTORY
Has any blood relative had: If “yes”, indicate relationship
YES NO
Birth abnormalities……………………
Cancer…………………………………
Diabetes………………………….…...
Heart problems……………………….
High blood pressure………………….
Other
FOR UPDATE ONLY
MEDICAL HISTORY REVIIEWED/UPDATED ON: ______PTS. INITIALS ______