All information is strictly confidential.
Today's Date
Name
Age
Reason for Visit
For InjuriesDate of Injury
On the job?
Occupation
Height
Weight
What is the most you have ever weighed
Past Medical HistoryPlease check if you have, or ever had any of the following conditions:
Cardiovascular
Respiratory
Gastro-intestinal
Blood
Neurologic
Mental Health
Skin/Skeletal
Immune/Infection
Endocrine
Others
Impairment
Cancer
Are you being treated for any other illness at this time?
If yes, please explain:
Date of Last Physical
Results
Have you ever had Surgery?
If yes, please list
Have you, or a family member ever had a problem with anesthesia?
If yes, please explain
Have you been diagnosed with a sleep disorder/sleep apnea?
Do you use a C-Pap Machine for your sleep disorder?
Do you have any Drug Allergies?
If yes, please note name of drug and reaction:
Family HistoryOnly list blood-related relatives.
Diabetes
Stroke
Blood Clots
Heart Disease
High Blood Pressure
Cancer/Type
Other
List all medications you are taking with name and dosage
Weight Control
Accutane (past year)
Antibiotics
Aspirin/NSAID's
Blood Thinners
Birth Control
Estrogen/Hormones
Chemotherapy
Antidepressants
Steroids
Vitamins/Supplements
Herbal/Homeopathics
Are you taking or have you ever taken recreational drugs?
What type
Please give more details
Do you smoke?
Quit?
How much per day?
Do you drink?
Additional Health History (Female Gender or FtM, please complete)
Pregnancies
Live Births
Miscarriages
Abortions
Date of Last Menstrual Period
Are you pregnant?
Date of Last Mammogram
Breast Cancer
History of Breast Biopsy
Current Bra Size (Female Gender Only)
Review of SystemsSelect the following symptoms you have had recently.
General
Eyes, Ears, Nose & Throat
Gastrointestinal
Genitourinary
Musculoskeletal
Psychiatric
Heme/Immunologic
Endocrine/Hormonal
Skin Disease
Breasts
To the best of my knowledge, the above information is complete and correct. I understand it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
Signature of Patient, Parent, Guardian, or Personal Representatives
Date
Time
Name of Patient, Parent, Guardian or Personal Representative
One fine body…
