Date of Visit: _______________ PATIENT INFORMATION Patient Name: __________________________________________________ Age: _______ DOB: _______________ HISTORY OF CHIEF COMPLAINT What body part are you seeing the doctor for today? Right Left Bilateral ______________________________ Please explain the reason for today’s visit: ___________________________________________________________ How did it start? ________________________________________________ When? _________________________ Was this caused by injury? Yes No If yes, when was the date of injury? _______________________________ Have you had any X-Rays, MRI, CT? Yes No If yes, when? _________________ When? ___________________ VITALS Pain Scale: 0 1 2 3 4 5 6 7 8 9 10 Height: _______________________ Weight: _____________________ MEDICATIONS (include over the counter) Medication Dose Prescribing Dr ALLERGIES List Allergies and reactions: None Latex Allergy Tape Allergy Iodine/Betadine Egg Allergy Allergy: _____________________________ Reaction: __________________________________ Allergy: _____________________________ Reaction: __________________________________ Allergy: _____________________________ Reaction: __________________________________ PROVIDERS Primary Care Doctor: _____________________________________________________________ PHARMACY Preferred Pharmacy: ____________________________________ Ph# _____________________ SURGICAL HISTORY Please check if you have had any of these surgeries in the past: None Ankle Surgery Defibrillator Hip Replacement Pacemaker Appendectomy Elbow Surgery Hip Surgery Shoulder Replacement Back Surgery Gallbladder Surgery Hysterectomy Shoulder Surgery Breast Surgery Gastric Bypass Knee Replacement Thyroidectomy CAGB Hand Surgery Knee Surgery Tonsillectomy Carpal Tunnel Release Heart Surgery Neck Surgery Other:_____________ C/Section Hernia Repair ORIF of ________ Other:_____________ PAST MEDICAL HISTORY AIDS/HIV Dialysis Migraine Headaches Anemia DVT/Phlebitis Osteoarthritis Arthritis Fibromyalgia Osteoporosis Asthma GERD Rheumatoid Arthritis Bleeding Disorder GI Bleed Seizures Blood Clotting Disorder Gout Stroke Blood Thinners Heart Disease Thyroid Disease Cancer Hepatitis Type:____ Ulcers COPD Hypertension Other: _______________________________ Depression Kidney Disease Other: _______________________________ Diabetes Liver Disease Other: _______________________________ FAMILY HISTORY Tell us about any family members who have or have had major health problems: Unknown/Adopted Mother: Alive Deceased Health Problems: _______________________________________ Father: Alive Deceased Health Problems: _______________________________________ Siblings: Brother Sister Alive Deceased Health Problems: _________________________ SOCIAL HISTORY Marital Status: Married Single Divorced Separated Widowed Domestic Partner Hand Dominance: Right Left Bilateral Exercise Level: None Occasional Moderate Heavy Are you currently employed? Yes No Employer: ___________________________________ Occupation: ___________________________________________________________________ Smoking Status: Never Smoker Former Smoker Current Every Day Smoker How much? __________________ Illicit Drugs: __________________ Alcohol Intake: None Occ Moderate Heavy Are you pregnant: Yes No Is this a work related injury?: Yes No If you were injured, is litigation ongoing: Yes No Fever Night Sweats Weight Gain/Loss Vision Changes Hearing Loss Nose/Sinus Problems Chest Pain Irregular Heartbeat Y N REVIEW OF SYSTEMS Y N Y Cough Fainting Spells Shortness of Breath Weakness Cough with Blood Numbness Abdominal Pain Dizziness Vomiting Headaches Diarrhea Fatigue Difficulty Urinating Swollen Glands Rash Itching/Hives N _________________________________ _______________ ___________________________ Patient Signature Date Provider Signature