Untitled Document

Date

Patient Name Date of Birth

Occupation Height Weight Shoe Size

Social History

Do you smoke?	Yes (list number of packs per day)	No
Do you drink alcohol?	Yes (list number of drinks per day)	No
Do you take recereational drugs?	Yes (list types)	No
Do you actively participate in sports?	Yes (list types)	No

Physical History (Check all that apply)

Aids	Difficulty Breathing	Malaria	Polio
Alzheimer's	Diphtheria	Measles	Raynaud's
Anemia	Epilepsy	Mitral valve prolapse	Rheumatic fever
Aneurysm	Glaucoma	Mumps	Scarlet fever
Ankle swelling	Gout	Muscular weakness	Sleep Apnea
Arthritis	Headaches	Narcolepsy	Stomach ulcer
Asthma	Hepatitis	Neurological problems	Stroke
Blood clots	Heart disease	Osteoporosis	Thyroid disorder
Blood disorder	High blood pressure	Palpitations	Tuberculosis
Bleeding tendency	Kidney disease	Paralysis	Venereal disease
Cancer (specify)	Liver disease	Parkinson's	Other (specify)
Chicken pox	Low back pain	Peripheral vascular disease
Diabetes	Lupus	Pleurisy
Other/additional information

Physical History (check all the apply)

Have you had problems with any of the following:
Eyes:	Cataracts	Macular Degeneration	Glaucoma	Glasses	Contacts
Head:	Concussion	Trauma
Ears:	Ringing of ears	Dizziness	Hearing Aids	Hearing Loss	Meniere's
Nose:	Sinus	Allergies
Throat:	Strep Throat	Tonsillitis	Cancer
Lungs:	Emphysema	Cancer	Shortness of Breath
GI:	Ulcer	Intestinal Problems	Crohn's	GERD	Irritable Bowel Syndrome
Skin:	Non-healing Sores	Eczema	Psoriasis
Joints:	Rheumatoid Arthritis	Degenerative Arthritis	Joint Implants	Gout
Muscles:	Fibromyalgia	Muscular Dystrophy	Multiple Sclerosis

Are you pregnant?

Surgery History	Please list all surgeries and any complications with anesthesia:

Present Medical Conditions:

Injury History:	Please list all broken bones, sprains, etc.

Do you have any pins, screws, plates, or implants?	Yes (list)	No
Do you have any joint replacements?	Yes (list)	No
Do you have a heart pace maker?	Yes (list)	No

Present Medications:

Please list all medications, amounts and frequency taken. Please include all over-the-counter medicines (ie: Ginkoba, Asprin, Vitamins)

Allergies or Medicines Not Tolerated:	Please list all known allergies and the type of reaction:

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