Patient Name
Today’s Date
Instructions to Fill Out Form:
1. ►Please print all the answers◄
2. ►Please mark an answer in each category◄
3. ► Complete the Medical Disclaimer ◄
CO-MORBIDITIES: MUSCULOSKELETAL/ORTHOPAEDIC
Musculoskeletal/Orthopaedic History
Please check Yes or No if you have any of the following?
[ ] No [ ] Yes ►Fracture History
[ ] No [ ] Yes ►Joint Injury/Disease
[ ] No [ ] Yes ►Musculoskeletal/Orthopaedic Surgery
Please provide information below if you have answered Yes:
CO-MORBIDITIES: MEDICAL/SURGICAL/SOCIAL
Allergies to Medications or Agents
Please check Yes or No if you have any of the following?
[ ] No [ ] Yes ►Tape
[ ] No [ ] Yes ►Local anesthetics [Novocaine,
[ ] No [ ] Yes ►Latex
Lidocaine]
[ ] No [ ] Yes ►Injected contrast agents
[ ] No [ ] Yes ►Non-steroidal anti-inflammatory
[ ] No [ ] Yes ►Iodine
[ ] No [ ] Yes ►Aspirin
[ ] No [ ] Yes ►General anesthetics
[ ] No [ ] Yes ►Opioids
[ ] No [ ] Yes ►Metals
[ ] No [ ] Yes ►Muscle relaxants
Please provide information below if you have answered Yes:
Please have any medicines and/or allergies listed reviewed by your internal medicine
specialist or family practitioner. The process of medicine reconciliation is the analysis of
medicines taken by the patient and proposed for use by the patient reviewed for the
appropriate indications and potential contraindications. Specific risks related to
medication [drug] to medication [drug] interactions or potential allergic responses to
medications [drugs].
Medications
Please check Yes or No if you have any of the following?
[ ] No [ ] Yes ►Medications prescribed
[ ] No [ ] Yes ►Over the counter medications
Please provide information below if you have answered Yes:
Please have any medicines and/or allergies listed reviewed by your internal medicine
specialist or family practitioner. The process of medicine reconciliation is the analysis of
medicines taken by the patient and proposed for use by the patient reviewed for the
appropriate indications and potential contraindications. Specific risks related to
medication [drug] to medication [drug] interactions or potential allergic responses to
medications [drugs].
Hospitalizations or ER Visits
Please check Yes or No if you have any of the following?
[ ] No [ ] Yes ►Hospitalizations
[ ] No [ ] Yes ►ER Visits
Please provide information below if you have answered Yes:
Surgical History
Please check Yes or No if you have any of the following?
[ ] No [ ] Yes ►Prior surgery
Please provide information below if you have answered Yes:
Medical History
Please check Yes or No if you have any of the following?
Cancer
Gastrointestinal Disease
[ ] No [ ] Yes ►Cancer of any origin and metastasis
[ ] No [ ] Yes ►Reflux or hiatal hernia
[ ] No [ ] Yes ►Gastric ulcer
Constitutional
[ ] No [ ] Yes ►Obesity
[ ] No [ ] Yes ►Duodenal ulcer
[ ] No [ ] Yes ►Hepatitis
Eyes
[ ] No [ ] Yes ►Cataracts
[ ] No [ ] Yes ►Cirrhosis
[ ] No [ ] Yes ►Glaucoma
[ ] No [ ] Yes ►IBS or irritable bowel syndrome
[ ] No [ ] Yes ►Crohn’s disease
Ear, Nose & Throat
[ ] No [ ] Yes ►Recurrent or chronic sinus infections
[ ] No [ ] Yes ►Ulcerative colitis
[ ] No [ ] Yes ►Vestibular disease
[ ] No [ ] Yes ►Pancreatitis
[ ] No [ ] Yes ►Liver failure
Cardiovascular Disease
[ ] No [ ] Yes ►Heart attack [MI]
[ ] No [ ] Yes ►Gallbladder disease/gallstones
[ ] No [ ] Yes ►Heart failure [CHF]
[ ] No [ ] Yes ►GI bleeding
[ ] No [ ] Yes ►Coronary artery disease
Kidney and Urinary Disease
[ ] No [ ] Yes ►High blood pressure
[ ] No [ ] Yes ►Kidney failure
[ ] No [ ] Yes ►Heart Valve Dysfunction
[ ] No [ ] Yes ►Recurrent urinary tract infections
[ ] No [ ] Yes ►Angina
[ ] No [ ] Yes ►Kidney stone
[ ] No [ ] Yes ►Arrhythmia
[ ] No [ ] Yes ►Prostate disease if male
[ ] No [ ] Yes ►Lipid disorder [elevated cholesterol
Musculoskeletal Disease
[ ] No [ ] Yes ►Gout
Vascular Disease
[ ] No [ ] Yes ►Varicose veins
[ ] No [ ] Yes ►Rheumatoid arthritis
[ ] No [ ] Yes ►Peripheral artery disease
[ ] No [ ] Yes ►Osteoarthritis
[ ] No [ ]Yes ►Peripheral venous disease
[ ] No [ ] Yes ►Lupus
[ ] No [ ] Yes ►Thrombophlebitis
[ ] No [ ] Yes ►Psoriasis
[ ] No [ ] Yes ►Venous blood clots
[ ] No [ ] Yes ►Osteoporosis
[ ] No [ ] Yes ►Arterial blood clots
[ ] No [ ] Yes ►Ankylosing Spondylitis
[ ] No [ ] Yes ►Pulmonary embolism
[ ] No [ ] Yes ►Fibromyalgia
[ ] No [ ] Yes ►Polymyalgia Rheumatica
Hematology Disease
[ ] No [ ] Yes ►Bleeding disorders
[ ] No [ ] Yes ►Tendon/muscle/joint disease or injury
[ ] No [ ] Yes ►Sickle cell
Skin Disease
[ ] No [ ] Yes ►Past blood transfusion
[ ] No [ ] Yes ►Dermatitis
[ ] No [ ] Yes ►Anemia
[ ] No [ ] Yes ►Eczema
[ ] No [ ] Yes ►Blood coagulation problem
Neurological Disease
[ ] No [ ] Yes ►Migraine
Infectious Disease
[ ] No [ ] Yes ►Chronic systemic infections
[ ] No [ ] Yes ►Stroke
[ ] No [ ] Yes ►Recurrent infections
[ ] No [ ] Yes ►TIA
[ ] No [ ] Yes ►Endocarditis
[ ] No [ ] Yes ►Seizures
[ ] No [ ] Yes ►Herpes
[ ] No [ ] Yes ►Parkinson’s disease
[ ] No [ ] Yes ►Tuberculosis
[ ] No [ ] Yes ►Peripheral neuropathy
[ ] No [ ] Yes ►HIV
[ ] No [ ] Yes ►Concussion or head injury
[ ] No [ ] Yes ►Meningitis
Endocrine Disease
[ ] No [ ] Yes ►Diabetes
Psychiatric
[ ] No [ ] Yes ►Thyroid disease
[ ] No [ ] Yes ►Anxiety disorder
[ ] No [ ] Yes ►Personality disorder
Respiratory Disease
[ ] No [ ] Yes ►Asthma
[ ] No [ ] Yes ►Depression diagnosis
[ ] No [ ] Yes ►Emphysema
[ ] No [ ] Yes ►Eating disorder
[ ] No [ ] Yes ►Chronic bronchitis
[ ] No [ ] Yes ►Psychosis
[ ] No [ ] Yes ►Recurrent pneumonia
[ ] No [ ] Yes ►Schizophrenia
[ ] No [ ] Yes ►Chronic obstructive pulmonary disease [ ] No [ ] Yes ►Post traumatic stress disorder
[ ] No [ ] Yes ►Respiratory failure
[ ] No [ ] Yes ► History of suicide attempt
Please provide any additional information regarding diseases/conditions in your Medical History not listed
above:
Review of Systems
Please check Yes or No if you have any of the following?
Constitutional
Neurologic
[ ] No [ ] Yes ►Chills
[ ] No [ ] Yes ►Ataxia or gait disorder
[ ] No [ ] Yes ►Fatigue
[ ] No [ ] Yes ►Coma history
[ ] No [ ] Yes ►Fever
[ ] No [ ] Yes ►Confusion
[ ] No [ ] Yes ►Weight loss
[ ] No [ ] Yes ►Feinting or blackouts
[ ] No [ ] Yes ►Weight gain
[ ] No [ ] Yes ►Headaches
[ ] No [ ] Yes ►History of paralysis
Eyes
[ ] No [ ] Yes ►Blurred vision
[ ] No [ ] Yes ►Involuntary movements
[ ] No [ ] Yes ►Double vision
[ ] No [ ] Yes ►Memory loss
[ ] No [ ] Yes ►Pain
[ ] No [ ] Yes ►Numbness or tingling
[ ] No [ ] Yes ►Vision loss
[ ] No [ ] Yes ►Seizure
[ ] No [ ] Yes ►Speech difficulties
ENT
[ ] No [ ] Yes ►Bleeding gums
[ ] No [ ] Yes ►Tremor
[ ] No [ ] Yes ►Ear ringing
[ ] No [ ] Yes ►Dizziness or loss of balance
[ ] No [ ] Yes ►Ear pain
Endocrine
[ ] No [ ] Yes ►Hearing loss
[ ] No [ ] Yes ►Cold intolerance
[ ] No [ ] Yes ►Hoarseness
[ ] No [ ] Yes ►Excessive hunger
[ ] No [ ] Yes ►Loss of taste
[ ] No [ ] Yes ►Excessive thirst
[ ] No [ ] Yes ►Nasal polyps
[ ] No [ ] Yes ►Heat intolerance
[ ] No [ ] Yes ►Nosebleeds
Hematologic
[ ] No [ ] Yes ►Recurrent sore throat
[ ] No [ ] Yes ►Bleeding tendencies
[ ] No [ ] Yes ►Swallowing difficulty
[ ] No [ ] Yes ►Easy bruising
Cardiovascular
Allergic/Immunologic
[ ] No [ ] Yes ►Chest pain
[ ] No [ ] Yes ►History of recurrent infections
[ ] No [ ] Yes ►Heart murmur
[ ] No [ ] Yes ►Night sweats
[ ] No [ ] Yes ►Palpitations
[ ] No [ ] Yes ►Sensitivity to pollen
[ ] No [ ] Yes ►Shortness of breath
[ ] No [ ] Yes ►Hay fever
[ ] No [ ] Yes ►Leg and/or ankle swelling
Genitourinary
[ ] No [ ] Yes ►Difficulty urinating
Respiratory
[ ] No [ ] Yes ►Persistent cough
[ ] No [ ] Yes ►Incontinence
[ ] No [ ] Yes ►Coughing up blood
[ ] No [ ] Yes ►Discharge
[ ] No [ ] Yes ►Wheezing
[ ] No [ ] Yes ►Blood in urine
[ ] No [ ] Yes ►Sputum production
[ ] No [ ] Yes ►Burning urination
[ ] No [ ] Yes ►Change in urination pattern
Gastrointestinal
[ ] No [ ] Yes ►Abdominal pain
[ ] No [ ] Yes ►Painful urination
[ ] No [ ] Yes ►Black tarry stools
[ ] No [ ] Yes ►Excessive night urination
[ ] No [ ] Yes ►Diarrhea
Skin
[ ] No [ ] Yes ►Heartburn
[ ] No [ ] Yes ►Rashes
[ ] No [ ] Yes ►Jaundice
[ ] No [ ] Yes ►Itching
[ ] No [ ] Yes ►Nausea
[ ] No [ ] Yes ►Hives
[ ] No [ ] Yes ►Rectal bleeding
Psychiatric
[ ] No [ ] Yes ►Reflux
[ ] No [ ] Yes ►Anxiety
[ ] No [ ] Yes ►Vomiting
[ ] No [ ] Yes ►Mood changes
[ ] No [ ] Yes ►Vomiting blood
[ ] No [ ] Yes ►Depression
[ ] No [ ] Yes ►Delusions
Musculoskeletal
[ ] No [ ] Yes ►General muscle stiffness
[ ] No [ ] Yes ►Hallucinations
[ ] No [ ] Yes ►Joint pain
Sex
[ ] No [ ] Yes ►Joint stiffness
[ ] No [ ] Yes ►Erectile dysfunction [male]
[ ] No [ ] Yes ►Muscle cramps
[ ] No [ ] Yes ►Impotence [male]
[ ] No [ ] Yes ►Joint dislocation
[ ] No [ ] Yes ►Currently pregnant [female]
[ ] No [ ] Yes ►Fracture
[ ] No [ ] Yes ►Possibly pregnant [female]
Please provide any additional information regarding diseases/conditions in your Review of Systems not listed
above:
Family History
Please check Yes or No if you have any of the following?
[ ] No [ ] Yes ►Allergy to anesthetics
[ ] No [ ] Yes ►Diabetes
[ ] No [ ] Yes ►Anemia
[ ] No [ ] Yes ►Thyroid disease
[ ] No [ ] Yes ►Asthma
[ ] No [ ] Yes ►Kidney disease
[ ] No [ ] Yes ►Lung disease
[ ] No [ ] Yes ►GI disease
[ ] No [ ] Yes ►Heart disease
[ ] No [ ] Yes ►Seizure
[ ] No [ ] Yes ►High blood pressure
[ ] No [ ] Yes ►Stroke
[ ] No [ ] Yes ►Bleeding disorders
[ ] No [ ] Yes ►Neurological disease
[ ] No [ ] Yes ►Cancer
[ ] No [ ] Yes ►Rheumatologic disease
Please provide any additional information regarding diseases/conditions in your Family History not listed above:
Social History
Work
Smoking
Substances Alcohol
Substances Prescribed
Drugs
Substances Non-Prescribed
Drugs [Cocaine, Heroin,
etc.]
Please check Yes or No if you have any of the following?
If No →
[ ] ►Temporarily Disabled due to Injury
[ ] ►Temporarily Disabled due to Medical Condition
[ ] ►Permanent Disability
[ ] ►Retired
[ ] ►Unemployed
If Yes→ [ ] ►Working in Regular Occupation
[ ] ► Working but in a Different Occupation from Regular Occupation
[ ] ►Working in Modified Job Capacity
[ ] ►Working at Home without Financial Compensation
[ ] ►Working as a Volunteer without Financial Compensation
If No→
[ ] ►Not smoking Now but have smoked in the Past
[ ] ►Never smoked
If Yes→ [ ] ►Currently smoking
If No→
[ ] ►No alcohol use
[ ] ►Recovering alcoholic
If Yes→ [ ] ►Alcohol occasional use
[ ] ►Alcohol light use
[ ] ►Alcohol moderate use
[ ] ►Alcohol heavy use
[ ] ►Alcoholic
If No→
[ ] ►No Prescribed Drug Abuse
If Yes→
If No→
If Yes→
[ ] ►Yes Current Prescribed Drug Abuse
[ ] ►Yes Past Prescribed Drug Abuse
[ ] ►No Non-Prescribed Drug Abuse
[ ] ►Yes Current Non-Prescribed Drug Abuse
[ ] ►Yes Past Non-Prescribed Drug Abuse
Please provide any information regarding Prescribed or Non-Prescribed Drug Abuse if any of the questions
answered yes:
Medical Disclaimer
[ ] No [ ] Yes
Please check Yes or No if you have completed the following?
I have reviewed the following Medical Disclaimer and understand it.
The information gathered in the Musculoskeletal/Orthopaedic History, Medical
History, Medications, Surgical History, Family History, Review of Systems and
Social History is utilized by Dr. Dillin to aid in the decision making process as it
applies to spinal conditions/diagnosis and spine oriented treatment. The information
obtained is not intended as a component of a general medical examination for
general health purposes. The information gathered reviewing these sections may be
utilized by the patient for consultation and review by a physician of the patient's
choice. Any positive responses revealed in these sections should be analyzed by the
patient's internal medicine or family practitioner for potential implications relating
to medical conditions/diseases and their diagnosis and treatment. Dr. Dillin is a subspecialist in spine medicine and spine surgery and his practice is limited to
conditions/diseases, diagnosis and treatment related to the spine only. Dr. Dillin is
not trained in general medicine and is not qualified to review and comment on
information gathered in the above sections, unless these areas directly apply to
spine related issues. Dr. Dillin does not review these areas to discover new medical
conditions/diseases, old medical conditions/diseases or potentially undiscovered
medical conditions/diseases. This role is the function of the internal medicine
specialist or family practitioner. Please see your internal medicine specialist or
family practitioner to rule out any non-spinal causes for you symptoms.