Medical History Form

Please take a few minutes to complete this medical history form.

Appointment Date:

Time:

Last Name:

First Name:

Date of Birth:

Gender:

Date of Injury or Onset of Problem:

Date of Surgery (if applicable):

Briefly describe the problem you were referred for:

If you have had this problem before, enter the date that you previously had the problem:

What specific activities, positions or movements worsen your symptoms?

What reduces your symptoms?

On a scale of 0 to 10 (0 being no pain and 10 being pain so severe that death or permanent impairment must occur within a few minutes), how would you rate your pain?


Pain Diagram

Please complete the "Pain Diagram" by dragging the letters in the key below to indicate your areas of pain in the diagram.

Drag and drop
onto diagram
Pain Pain Pain Pain Pain Pain Pain Pain
Pain
Numbness Numbness Numbness Numbness Numbness Numbness Numbness Numbness
Numbness
Stiffness Stiffness Stiffness Stiffness Stiffness Stiffness Stiffness Stiffness
Stiffness
Burning Burning Burning Burning Burning Burning Burning Burning
Burning
Tingling Tingling Tingling Tingling Tingling Tingling Tingling Tingling
Tingling
Other Other Other Other Other Other Other Other
Other

Medication Information

Please list your current medication and supplements. It is important that you include your dose and frequency.

 

Medication:

Dose:

How many per day:

How often per day:

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How many per day:

How often per day:

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Medication:

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Medication:

Dose:

How many per day:

How often per day:

Additional medications:

Please list any allergies to medications and your adverse reaction to the medication:

Medication:

Reaction to medication:

Medication:

Reaction to medication:

Medication:

Reaction to medication:

Medication:

Reaction to medication:

Medication:

Reaction to medication:

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Medication:

Reaction to medication:


Review of Systems

Please review the following and indicate all that apply:

Constitutional

Activity change

Chill/shakes

Decreased appetite

Fatigue

Fever

Insomnia

Weight gain - How much:

Weight loss - How much:

Irritability

Weakness

Lethargy (decreased energy)

Malaise (vague feeling of discomfort)

Night sweats

Head, Ears, Eyes & Throat

Headache - Describe:

Visual changes

Double vision

Decreased vision

Spots, flashing, etc.

Hard of hearing

Tinnitus (ringing in ears)

Choking

Difficulty swallowing liquids

Difficulty swallowing solids

Change in voice - Describe:

Respiratory/Thorax

Pleuritic pain (painful breathing)

Shortness of breath

Wheezing

Cardiovascular

Chest pain with:

Exertion

Resting

Both - Location:

Edema (swelling) of:

Hands

Feet

Palpitations (irregular heart beat)

Vascular

Claudication (pain in legs or buttocks with walking)

Cyanosis (purple or dark blue feet) - Location:

Erythema (redness of limbs) - Location:

Ulcers (sores on feet)

Blood Clots - Location: - When:

Gastrointestinal

Abdominal pain

Black stools

Altered bowel habits - Describe:

Genitourinary

Dysuria (painful urination)

Hematuria (blood in urine)

Increased frequency of urination - How often:

Incontinence (inability to control urine excretion)

Increased urgency

Metabolic/Endocrine

Cold intolerance

Heat intolerance

Hair loss

Coarse hair

Change in sleep/wake cycle

Generalized weakness

Polydipsia (excessive thirst)

Polyphagia (excessive hunger)

Neurology/Psychology

Difficulty speaking

Aphasia (difficulty finding words or use of wrong or nonsense words)

Dysarthria (difficulty pronouncing words)

Gait (walking) disturbance - Describe:

Focal weakness in:

Leg:

Arm:

Face:

Incoordination - Where:

Paresthesias (numbness/tingling) - Where:

Lightheadedness/Dizziness

Fainting spells

Vertigo (sense of room spinning)

Irritable

Frequently tearful

Decreased sense of self-worth

Feelings of guilt

Loss of pleasure

Decreased energy

Thoughts of harming yourself or others

Dermatologic

Hair changes - Describe:

Nail changes - Describe:

Pruritis (itching)

Rash - Where: Describe:

Hematologic

Easy bruising

Bleeding problems - Describe:

Lymphadenopathy (swollen glands)

Musculoskeletal

Back pain in:

Upper Region

Lower region

Neck pain

Myalgias (muscle pain) - Where:

Rheumatologic manifestations (hot/red/swollen joints) - Where:

Joint pain in:

Shoulder

Elbow

Wrist

Fingers

Hip

Knee

Ankle

Feet/Toes

Immunological

Allergy to tape

Allergy to latex

Allergy to:


Past Medical & Family History

Adopted or unknown family history

Have you or a family member ever been diagnosed with the following?

Rheumatological

Rheumatoid Arthritis:
You Father Mother Brother Sister

Osteoarthritis:
You Father Mother Brother Sister

Psoariatic Arthritis
You Father Mother Brother Sister

Lupus
You Father Mother Brother Sister

Vasculitis
You Father Mother Brother Sister

Other:

You Father Mother Brother Sister

Cancer

Type:

You Father Mother Brother Sister

Type:

You Father Mother Brother Sister

Type:

You Father Mother Brother Sister

Type:

You Father Mother Brother Sister

Heart/Vascular Disease

Heart attack:
You Father Mother Brother Sister

Bypass surgery:
You Father Mother Brother Sister

Coronary artery disease:
You Father Mother Brother Sister

High blood pressure:
You Father Mother Brother Sister

Anemia:
You Father Mother Brother Sister

Lung Disease

COPD:
You Father Mother Brother Sister

Asthma:
You Father Mother Brother Sister

Bronchitis:
You Father Mother Brother Sister

Other:

You Father Mother Brother Sister

Endocrine

Diabetes Diagnosis date:

You Father Mother Brother Sister

Thyroid disease:
You Father Mother Brother Sister

Osteoporosis:
You Father Mother Brother Sister

Gastrointestinal

Stomach ulcer:
You Father Mother Brother Sister

GERD/Gastritis (heartburn):
You Father Mother Brother Sister

Liver Disease

Hepatitis A:
You Father Mother Brother Sister

Hepatitis B:
You Father Mother Brother Sister

Hepatitis C:
You Father Mother Brother Sister

Cirrhosis:
You Father Mother Brother Sister

Other:

You Father Mother Brother Sister

Kidney Disease

Renal failure:
You Father Mother Brother Sister

Stones:
You Father Mother Brother Sister

Other:

You Father Mother Brother Sister

Neurological

Stroke:
You Father Mother Brother Sister

Multiple sclerosis:
You Father Mother Brother Sister

Seizure disorder:
You Father Mother Brother Sister

Peripheral neuropathy:
You Father Mother Brother Sister

Carpal tunnel syndrome:
You Father Mother Brother Sister

Alzheimer's disease:
You Father Mother Brother Sister

Dementia:
You Father Mother Brother Sister

Psychiatric

Depression:
You Father Mother Brother Sister

Bipolar disorder:
You Father Mother Brother Sister

Schizophrenia:
You Father Mother Brother Sister

Personality disorder:
You Father Mother Brother Sister

Drug abuse - Which drug(s):

You Father Mother Brother Sister

Alcoholism:
You Father Mother Brother Sister

Have you ever had any of the following:

Herniated disk in:

Cervical (neck) region

Lumbar (low back) region

Surgery date:

Fractured spine in:

Cervical

Thoracic (mid back)

Lumbar

Surgery date:

Injury to joint(s)

Shoulder:

Elbow:

Wrist:

Knee:

Other:

Please list any surgeries that you have had:

Date:      Surgery:

Date:      Surgery:

Date:      Surgery:

Date:      Surgery:

Date:      Surgery:

Date:      Surgery:

Date:      Surgery:

Date:      Surgery:

Is there anything else that you would like the Doctor to know about your health history?


Social History

Primary language spoken:

Right handed Left handed Ambidextrous

Highest grade completed in school:

Highest degree/diploma completed:

Employer:

Occupation:

Unemployed Disabled Retired

Date last worked:

Retired as of:

Married Significant other/Partner Divorced Widowed Single

Children   Number of children:

Tobacco

Current, every day Current, some days Never Former Year quit:

Type of tobacco:

Alcohol

No Yes - Type:

How Much: How Often:

Former, Year quit:

I do regular exercises   Type:    Frequency:

Please list any hobbies/leisure activities that you are involved in:

Please check this box if you want a chaperone present during your exam with the Doctor.

Thank you for taking the time to complete this packet.