Patient Medical History Patient Medical History First Name Middle Last Occupation Height DOB Weight Referring Physician When is your new patient appointment scheduled for? Chief Complaint/History of Present Illness Date of injury or onset of symptoms? Are you still working in spite of your illness/injury? Yes No Which body part is involved? List activities which cause pain Rate the pain (0 = no pain; 10 = most severe) What activities/medications help your condition? What previous treatment have you had for this problem? Are you right or left hand dominant? Medical History Please check any of the following that you have had: Diabetes: type 1 or 2 Yes No Thyroid Problems Yes No Heart Problems Yes No Blood Clots Yes No High Blood Pressure Yes No Stroke Yes No Seizures Yes No Asthma Yes No Tuberculosis (TB) Yes No Liver Problems Yes No Elevated Cholesterol Yes No Kidney, Bladder or Prostate Problems Yes No Stomach Ulcer or Reflux Problems Yes No Difficulty Opening Mouth Yes No Muscle Disorders Yes No Mental Health Disorders Yes No Skin Disorders Yes No Sleep Apnea Yes No Severe/Migrane Headaches Yes No Arthritis RA OA Yes No Cancer Yes No Cancer Type/Location Other serious health conditions Surgical History Surgery Date Physician Hospital City State Current Medications Medication Name Dosage (mg, mcg, etc.) Frequency (times per day, as needed, etc.) Allergies Are you allergic to latex? Yes No Are you allergic to any medications? Yes No If YES, list medication and reaction List any other allergies Social History Do you use tobacco? Yes No Form of tobacco Frequency of daily use (eg., 2 packs per day) Do you drink alcoholic beverages? Yes No Average # of drinks per week Do you have a history of substance abuse? Yes No Family History Has or does anyone in your family have any of the following? Heart Trouble Yes No Relationship: Diabetes Yes No Relationship: Tuberculosis Yes No Relationship: High Blood Pressure Yes No Relationship: Pneumonia Yes No Relationship: Cancer Yes No Relationship: Sudden Death Yes No Relationship & Cause: Arthritis Yes No Relationship: Musculoskeletal Do you have any chronic or intermittent back pain? Yes No Do you have any problems with any other joints such as pain, swelling, stiffness or weakness? Yes No If YES, please explain: Skin Do you have any rashes, lesions, lumps or sores? Yes No If YES, please explain: Neurological Do you have history of seizures or other nervous system disorders requiring medication? Yes No If YES, please explain: Do you have any previous history of stroke? Yes No Do you have any problems with headaches or dizziness? Yes No Psychiatric Do you have a drug or alcohol addiction? Yes No Do you have any problems with depression? Yes No Endocrine Do you have any problems with excessive thirst or intolerance to heat or cold? Yes No Hematology Do you have any problems with easy bleeding? Yes No Do you have any problems with easy bruising? Yes No Do you have any problems with anemia? Yes No Have you ever had a blood clot? Yes No Constitutional Have you had any recent coughs or colds? Yes No Eyes Do you have any tearing, eye pain, pressure or change in vision? Yes No If YES, please explain: Ear, Nose & Throat Do you have any sore throats? Yes No Do you have difficulty hearing? Yes No Cardiovascular Do you have any chest or arm pain on exertion? Yes No Do you have chronic cough either dry or with blood or sputum? Yes No Gastrointestinal Do you have gastritis? Yes No Do you have colitis? Yes No Do you have diverticulitis? Yes No Do you have hepatitis? Yes No Genitourinary Do you have prostate trouble? Yes no Do you have to get up at night to urinate? Yes no Do you have frequency of urination? Yes No Other Considerations Do you have vision or hearing disabilities? Yes No Please specify: Do you have any physical limitations? Yes No Please specify: Is there anything else we should know about you?