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?