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?
YesNo

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
YesNo

Thyroid Problems
YesNo

Heart Problems
YesNo

Blood Clots
YesNo

High Blood Pressure
YesNo

Stroke
YesNo

Seizures
YesNo

Asthma
YesNo

Tuberculosis (TB)
YesNo

Liver Problems
YesNo

Elevated Cholesterol
YesNo

Kidney, Bladder or Prostate Problems
YesNo

Stomach Ulcer or Reflux Problems
YesNo

Difficulty Opening Mouth
YesNo

Muscle Disorders
YesNo

Mental Health Disorders
YesNo

Skin Disorders
YesNo

Sleep Apnea
YesNo

Severe/Migrane Headaches
YesNo

Arthritis RA OA
YesNo

Cancer
YesNo

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?
YesNo

Are you allergic to any medications?
YesNo

If YES, list medication and reaction

List any other allergies

Social History

Do you use tobacco?
YesNo

Form of tobacco

Frequency of daily use (eg., 2 packs per day)

Do you drink alcoholic beverages?
YesNo

Average # of drinks per week

Do you have a history of substance abuse?
YesNo

Family History

Has or does anyone in your family have any of the following?

Heart Trouble
YesNo

Relationship:

Diabetes
YesNo

Relationship:

Tuberculosis
YesNo

Relationship:

High Blood Pressure
YesNo

Relationship:

Pneumonia
YesNo

Relationship:

Cancer
YesNo

Relationship:

Sudden Death
YesNo

Relationship & Cause:

Arthritis
YesNo

Relationship:

Musculoskeletal

Do you have any chronic or intermittent back pain?
YesNo

Do you have any problems with any other joints such as pain, swelling, stiffness or weakness?
YesNo

If YES, please explain:

Skin

Do you have any rashes, lesions, lumps or sores?
YesNo

If YES, please explain:

Neurological

Do you have history of seizures or other nervous system disorders requiring medication?
YesNo

If YES, please explain:

Do you have any previous history of stroke?
YesNo

Do you have any problems with headaches or dizziness?
YesNo

Psychiatric

Do you have a drug or alcohol addiction?
YesNo

Do you have any problems with depression?
YesNo

Endocrine

Do you have any problems with excessive thirst or intolerance to heat or cold?
YesNo

Hematology

Do you have any problems with easy bleeding?
YesNo

Do you have any problems with easy bruising?
YesNo

Do you have any problems with anemia?
YesNo

Have you ever had a blood clot?
YesNo

Constitutional

Have you had any recent coughs or colds?
YesNo

Eyes

Do you have any tearing, eye pain, pressure or change in vision?
YesNo

If YES, please explain:

Ear, Nose & Throat

Do you have any sore throats?
YesNo

Do you have difficulty hearing?
YesNo

Cardiovascular

Do you have any chest or arm pain on exertion?
YesNo

Do you have chronic cough either dry or with blood or sputum?
YesNo

Gastrointestinal

Do you have gastritis?
YesNo

Do you have colitis?
YesNo

Do you have diverticulitis?
YesNo

Do you have hepatitis?
YesNo

Genitourinary

Do you have prostate trouble?
Yesno

Do you have to get up at night to urinate?
Yesno

Do you have frequency of urination?
YesNo

Other Considerations

Do you have vision or hearing disabilities?
YesNo

Please specify:

Do you have any physical limitations?
YesNo

Please specify:

Is there anything else we should know about you?