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