PATIENT HISTORY FORM

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1 PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your last visit, please update any new or additional information. Patient s Name: Date of Birth: Date of visit: Age: Chief Complaint: RIGHT LEFT NA Is this a result of a: Motor Vehicle Accident? NO YES Date of Accident Work Related? NO YES Date of Injury If work related, WCB case # is Patient s usual work activities Are you currently working? NO YES Please describe how the injury occurred: What are your symptoms? How long had you had these symptoms? Please indicate by using a number Days Weeks Months Years MEDICAL HISTORY Medical Doctor/Internist Name Address Phone 1

2 What is your general state of health? Excellent Good Fair Poor Is there a possibility that you are pregnant? YES NO Are you currently being treated for any medical conditions? Alzheimer s NO YES Aneurism NO YES Anxiety NO YES Asthma NO YES Blood clots NO YES Blood clotting abnormalities NO YES Cancer NO YES Type: Cataracts NO YES COPD NO YES Defibrillator NO YES Dementia NO YES Depression NO YES Diabetes NO YES Emphysema NO YES Gastritis NO YES GERD NO YES Goiter NO YES Gout NO YES Heart Disease NO YES High Cholesterol NO YES Hypertension NO YES Hyperthyroidism NO YES Hypothyroidism NO YES Memory loss NO YES Osteoarthritis NO YES Osteoporosis NO YES Pacemaker NO YES Phlebitis NO YES PVD NO YES Renal Disease NO YES Rheumatoid Arthritis NO YES Sleep Apnea NO YES Stroke NO YES Ulcers NO YES Vascular Disease NO YES OTHER 2

3 MEDICATIONS Please list the Medications you are currently taking. Include over the counter medications MEDICATION DOSE MEDICATION S PURPOSE Are you currently taking vitamins other than a multivitamin? NO YES If YES, please list: Are you currently taking herbal medication? NO YES If YES, please list: SURGICAL HISTORY Any surgeries since your last visit? YES NO If yes, please fill fields below. Have you had any previous surgery? NO YES Please List Have you ever had a blood transfusion? NO YES Do you have a cardiac stent? NO YES Do you have a vascular stent? NO YES 3

4 NONE YES ALLERGIES DRUG Reaction DRUG Reaction LATEX NO YES Reaction METAL NO YES Reaction Have you ever fainted or had a reaction to an injection? NO YES PSYCHOSOCIAL Occupation Marital Status S M W D Hobbies/Sports Do you live alone? NO YES Do you smoke? NO YES If yes, how much? Packs/day Do you drink? NO YES If yes, how much? Drinks/day Other drug use? NO YES If Yes, please explain FAMILY HISTORY Any first order relatives with a history of thromboembolic events or bleeding disorders? NO YES 4

5 REVIEW OF SYSTEMS (All Patients Must Complete This Section) Are you currently experiencing any of these symptoms? Please check the symptoms that apply CONSTITUTION Chills Fever Sleep Difficulty Malaise/Fatigue Night Sweats Unintended weight loss HEMATOLOGICAL Easy bruising Bleeding DVT RESPIRATORY Increase Sputum Hemoptysis Shortness of breath SKIN Ulcers Nodules Lesion Hives/Urticaria Rash Jaundice Photosensitivity HEENT Double Vision Headaches Hearing Loss Cataracts Glaucoma Dry Eyes Sore Throat Swollen Glands CARDIOVASCULAR Chest Pain Edema Palpitations Dyspnea on Exertion Poor Circulation Neg ENDOCRINE Polyuria Polydypsia Cold Intolerance Heat Intolerance MSK Arthralgias Arthritis Muscle Pain Joint Swelling Muscle Cramps Muscle Weakness Joint Stiffness Soft Tissue Swelling GASTROINTESTINAL Neg Abdominal Pain Bowel Habit Change Trouble Swallowing Heartburn Nausea Vomiting Constipation Diarrhea Bleeding GENITOURINARY Bladder Incontinence Hematuria Urinary Difficulty Nocturia Dysuria Urinary Retention Urinary Urgency NEUROLOGICAL Tingling Dizziness Weakness Loss of Balance Numbness Difficulty Walking Memory Difficulty PSYCHIATRIC Depression Anxiety Mood Swings HEIGHT WEIGHT Patient s Signature PLEASE BE SURE WE HAVE THE CORRECT INSURANCE INFORMATION TO PROCESS YOUR CLAIM 5

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