Please complete all that applies to you and then print this entire file and bring it with you to your appointment. This will expedite your visit with your provider. Thank You!!

Today's Date:

Patient's Name: Date of Birth:

ARE YOU ALLERGIC TO ANY MEDICATION YES NO

IF YES, PLEASE LIST YOUR ALLERGIES HERE:

What is the name of your primary doctor or medical provider:

What is your height? What is your weight? Your age?

1. Present Illness:

I. What is your orthopaedic or medical problem & symptoms.                                        Right          Left

II.  When did the accident happened or your symptoms start?

IIb. Was there an accident or injury?

III. Have you seen any other doctors for this problem?

Who:

when:

what was their treatment:

IV. Give a step by step history of your condition. Give dates & any important changes or developments. (What happened. When did it happen. What have you done for your problem so far.)

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2. PAST MEDICAL HISTORY:

I. Please list all operations you ever had, date, and any complications:

II. Please list all other hospitalizations, date and reason:

III. Do you now have or have you ever had any of the following problems? (if yes to any of these problems please give details at the bottom):

HEART CONDITIONS               YES NO

HIGH BLOOD PRESSURE         YES NO

STROKE                                     YES NO

BLOOD DISORDERS                 YES NO

NERVE PROBLEMS                     YES NO

DIABETES OR THYROID DISEASE               YES NO

CHEST OR RESPIRATORY PROBLEMS       YES NO

STOMACH OR ABDOMINAL PROBLEMS   YES NO

KIDNEY OR URINARY PROBLEMS                YES NO

CANCER                                     YES NO

OTHER MEDICAL PROBLEMS                     YES NO

DETAILS TO YES ANSWERS:

IV. MEDICATIONS: Please list the names & doses of any medications you are now taking.

NAME OF MEDICINE

DOSE

V. Have you ever taken Cortisone or Prednisone by mouth or by injections? YES NO

VI. Do you drink alcohol? YES NO

If yes, how much? What kind?

VII. Do you smoke? YES NO If yes, how many a day?

what kind; Cigarettes pipe cigars Chewing Tobacco

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3. FAMILY HISTORY

	Age now or at time of death	Medical conditions including cause of death, if deceased
Father
Mother
Brothers
Sisters

Has anyone in your family:	YES NO	Who?
Had a tendency to bleed excessively?
Had unusual reactions to anesthesia?
Had unexpected fevers during or after surgery?
Had (T.B.) tuberculosis?
Had arthritis?
Had Hypertension?
Had cancer?
Had diabetes mellitus?
Had hip dislocations?
Had congenital deformities or birth defects

PERSONAL HISTORY

Place of birth:

What is the highest level of education you have obtained?

Marital status: Single Married Separated Divorced Widowed

What is your current occupation?

Do you live in a private home? Apartment? Other?

Is your home single level? or Multi level?

With whom do you live?

Do you require attendant help? Yes No

Do you have any children? Yes No How many?

Thank you for filling this form out in advance. Now print this entire form and bring it with you to your appointment. It will help expedite your visit with your provider.

In order not to interrupt your visit with your doctor or disturb other patients,

Please turn off your cell phone while in our office!!