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?