MEDICAL HISTORY FORM
Date: _______________________
Patient Name: __________________________________________
DO YOU HAVE ALLERGIES TO MEDICATION OR FOOD:  Yes
 No
Please list: _________________________________________________________________________________
Medication
List ALL medications you are currently taking
Dose (mg)
Drug
Frequency
Reason for visit
Please describe your injury in detail. Make sure to include date, time and location (ie. Work, School, MVA, etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
TESTS DONE RELATED TO PRESENT INJURY OR COMPLAINT:
 X-Rays
 MRI
 CT Scan
 EMG
 Bone Scan
 Bone Density
 Labs
Tests perfomed at: _____________________________________________________________________
PRIOR TREATMENT (if any; example: Anti-inflammatories, Surgery, Physical Therapy, injections etc.):
_____________________________________________________________________________________
 Pain
 Numbness / Tingling
 Limited Movement
Current Symptoms
 Swelling
 Locking/Catching
 Gait Problem
 Mass / Deformity
 Bruising
 Weakness
Pain level 0 – 10 ( 10 being the most severe ): _______
General Information
Weight: ___________
Height: ___________
Referred by a doctor?  Yes
 No
Doctors name: ___________________________
Handedness:  Right hand
 Left hand
 Ambidextrous
Patient Name: ______________________________
Review Of Systems
Please check all symptoms which you have experiened recently
Integumentary
 Rash
 Itching
 Wound
Hematologic
 Bruising
ENT
 Nosebleeds
Cardiovascular
 Chest Pain
 Palpatations
Respiratory
 Cough
 Shortness of Breath
Systemic
 Fever
 Weight Loss
 Weight Gain
 Fatigue
Endocrine
 Excessive Thrist
 Muscle Weakness
Psychiatric
 Depression
Urinary
 Burning during urination
 Urinary frequency
Gastrointestinal
 Indigestion
 Nausea
 Vomiting
 Diarrhea
 Constipation
Musculoskeletal
 Joint Pain, Diffuse
 Joint Pain, Localized
 Joint Swelling
Neurological
 Headache
 Dizziness
Past Medical History
 Acid Reflux
 Acute MI
 ADHD
 Alzheimer’s
 Anxiety
 Arthritis
 Asthma
 BPH
 Cancer: ______________
 Vascular Disorder
 CHF
 COPD
 Crohn’s Disease
 Dementia
 Depression
 Diabetes
 Glaucoma
 Gout
 Headache
 Heart Disease
 High Cholesterol
 High Blood Pressure
 Kidney Disease
 Lupus
 Lyme Disease
 MRSA
 Osteoporosis
 Parkinson’s Disease
 Scoliosis
 Seizures
 Thyroid Disorder
 TBI
 Other: _____________
Surgical History:
Family History:
Occupation:
 Appendectomy
 Tonsillectomy
 Gall Bladder
 Hernia Repair
 High Blood Pressure
 Heart Disease
 Stroke
 High Cholesterol
_________________________
 Retired
 On Disability
 Ear Tubes
 Coronary Angioplasty
 Coronary Bypass
 Cesarean Section
 Breast Surgery
D+C
 Hysterectomy
 Tubal Ligation
 Back Surgery
 Total Hip: right / left
 Total Knee: right / left
 Knee Scope: right / left
 Carpal Tunnel: right / left
 Rotator Cuff: right / left
 Prostate
 Other: ______________
 Thyroid Disease
 Blood Clots
 Osteoporosis
 Asthma
 Kidney Disease
 Diabetes
 Arthritis
 Cancer: _______________
Personal History:
Cigarettes:
 Daily – amount _________
 Sometimes
 Never
 Former – quit when ______
Alcohol:
 Yes – amount ___________
 No
Marital History:
 Single
 Married
 Disvorced
 Widowed