NEW PATIENT MEDICAL HISTORY FORM

Patient First Name

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Patient Last Name

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Height:

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Weight:

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Race:

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Ethnicity:

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Preferred Language:

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Other:

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Preferred Pharmacy:

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Referral Source: Doctor (name):

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Other (ex. Google search):

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Chief Complaint

Dominant Hand:

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Description of Symptoms: (select only ONE primary symptom and ONE affected area)

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Other:

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Shoulder

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Upper Arm

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Elbow

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Forearm

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Wrist

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Hand

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Thumb

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Index

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Middle

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Third

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Little

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Pelvis

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Hip

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Thigh

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Knee

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Lower Leg

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Ankle

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Foot

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Great Toe

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2nd Digit

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3rd Digit

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4th Digit

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5th Digit

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Neck

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Upper Back

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Mid Back

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Low Back

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Buttocks

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Tail Bone

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Pain radiates from/to: (ex. from low back to right leg)

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History of Present Illness

1. Is your problem the result of an injury or accident?

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How long have the symptoms been present? (ex. 2 days, 4 months)

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Describe the onset:

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Onset Date:

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2. Are you represented by an attorney?

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Attorney Name:

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Will there be any legal actions with respect to this problem?

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3. Have you had a problem like this before?

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Describe:

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4. Have you been seen in an ER for this problem?

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Treating ER: (ex. St. Luke’s Health)

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Date:

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5. Rate the pain (10 being the most pain):

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6. Do the symptoms wake you from sleep?

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7. Please describe the symptoms:

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8. What is the timing of the symptoms?

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9. Is the problem getting better or worse?

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10. What makes the symptoms worse?

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11. Are there any other symptoms associated with this problem?

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Prior Testing / Treatment

Have you had any prior tests for this problem?

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Have you had any prior treatment for this problem?

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Type of treatment

Ice

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Date of treatment

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Heat

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Date of treatment

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Rest

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Date of treatment

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NSAIDs

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Date of treatment

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Muscle Relaxers

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Date of treatment

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Chiropractor

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Date of treatment

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Physical Therapy

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Date of treatment

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Home Exercise Program

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Date of treatment

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Surgery

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Date of treatment

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Injections

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Date of treatment

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Bracing

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Date of treatment

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TENS unit

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Date of treatment

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Other/Comments:

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Select all previous hospitalizations/surgeries:

Aneurysm (Brain) Surgery

Aortic Bypass / Vascular Surgery

Appendectomy

Cataract (Eye) Surgery

Cholecystectomy (Gallbladder)

Heart Surgery

Hernia Repair

Hysterectomy

LAP Band / Gastric Bypass Surgery

Lumpectomy

Mastectomy

Malignancy/Cancer

Stents

None

Other Surgery

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Orthopedic on side

Arthroscopy: Knee

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Arthroscopy: Shoulder

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Carpal Tunnel Release

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Rotator Cuff Repair

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Total Hip Replacement

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Total Knee Replacement

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Total Shoulder Replacement

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Spinal Surgery - Indicate Level:

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Other Orthopedic Surgery

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Medical Questions

Mark all that currently apply:

Metal in body

Claustrophobic

Pregnant

Sleep Apnea

Uses a CPAP

Snores

Are you taking blood thinners?

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Review of Systems

Please indicate if you have experienced any of the following symptoms in the last 6 months?

1) CON

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Comments

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2) EYE

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Comments

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3) ENT

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Comments

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4) CV

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Comments

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5) RS

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Comments

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6) GI

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Comments

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7) GU

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Comments

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8) SK

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Comments

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9) NEU

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Comments

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10) PSY

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Comments

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11) ENDO

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Comments

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12) HEM

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Comments

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Family History

Have any direct relatives had any of the following disorders?

Father

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Comments (ex. cancer type)

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Mother

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Comments (ex. cancer type)

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Sibling

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Comments (ex. cancer type)

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Social History

Do you smoke tobacco?

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Do you drink alcohol?

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Marital Status:

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Are you currently working?

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If no, what date did you last work?

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Please list work restrictions, if any:

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Occupation:

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Employer:

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Student

Pain Diagram

List the body parts where do you experience pain.

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Do you have any allergies?

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If Yes, please list below:

Medication, Relevant Food, or “Seasonal”

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Reaction

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Medication, Relevant Food, or “Seasonal”

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Reaction

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Medication, Relevant Food, or “Seasonal”

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Reaction

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Latex allergy?

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Please list all medications you take on a regular basis:

None

Medication

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Dosage and Frequency (e.g. 20 mg, once/day)

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Medication

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Dosage and Frequency (e.g. 20 mg, once/day)

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Medication

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Dosage and Frequency (e.g. 20 mg, once/day)

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Do you have a personal history of any of the following?

None

Aneurysm

Where:

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Angina (Chest Pain)

Arthritis

Type:

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Asthma

Bone or Joint Infections

Cancer

Type:

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Chemotherapy / Radiation

COPD

Congestive Heart Failure

Diabetes

Type:

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Emphysema

Epilepsy

Heart Attack

Hepatitis

Type:

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HIV / AIDS

High Cholesterol

Hypertension

Hyperthyroidism

Hypothyroidism

Kidney Disease

Kidney Stones

MRSA Infection

Pacemaker

Phlebitis (Blood Clots)

Pulmonary Embolism

Reaction to Anesthesia

Type:

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Seizures

Stomach Ulcers

Stroke / TIA

Tuberculosis

Please list any other conditions or details of conditions marked above:

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Date

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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