THE BONE & JOINT CLINIC OF LAKE JACKSON
History
Name (Print) ____________________________________________________________________________________________Date: _____________________________
Pharmacy __________________________________________________Dr. ______________________________________Cardiologist ________________________
SOCIAL
 Have you had a Bone Density Scan within the last 2
 Alcohol – Heavy
years? Y N
 Alcohol – Moderate
 Have you had cortisone within the past year? Y  N
 Alcohol – Never
 Are/have you taking/ taken blood thinners?  Y  N
 Social drug use – No
 Do you have diabetes? Y N
 Social drug use – Yes
 Kidney problems? Y N
 Disabled
 Ulcers? Y N
 Employed What is your occupation? _________________
 High blood pressure (hypertension)?  Y N
 Retired
 Coronary artery disease (CAD)? Y N
 Unemployed
 Have you had a heart attack before? Y N
 Student
 Stroke? Y N Cancer? Y N If yes, list what
 Child
type/when: _____________________________________
 Exercise > 3 times per wk
 Please list your other medical conditions/diagnoses:
 Single
__________________________________________________
 Married
ALLERGIES
 Widow
 NONE
 Current Every Day Smoker
 Aspirin
 Current Some Days Smoker
 Antibiotics
 Former Smoker
 Codeine
 Never Smoker
 Darvon
 Smoker, Current Status Unknown
 Demerol
 Unknown If Ever Smoked
SURGERIES
 NONE
 Ankle
 Arthroscopy
 Back
 Carpal Tunnel
 Elbow
 Foot
 Hand
 Heart
 Hip
 Knee
 Pacemaker
 By pass, stent
 Shoulder
 Wrist
Other:
FAMILY HISTORY
 NONE
 Alzheimer’s
 Arthritis
 Bleeding disorders
 Diabetes
 Heart disease
 High blood pressure
REVIEW OF SYSTEMS
1. CONSTITUTIONAL NONE Fever Chills  Sweats  Fatigue
 Weight gain/loss
2. HEAD/NECK NONE  Headache  Vision change  Dizzy
 Lumps  Ear pain/discharge  Hearing change  Bleeding
3. CARDIAC NONE Chest pain  Irregular heart rate Short of
breath W/stairs  Cold sweat Heart disease
4. RESP NONE  Chronic cough  Bloody cough  Wheezing
 Pneumonia
5. GI NONE  Indigestion  Nausea  Abdominal pain
 Diarrhea  Heartburn/ulcers  Bloody stool  Hepatitis
6. GU  NONE  Painful urination  Urgent urination
 Frequent urination  Night time urination  Discharge
7. BONE/JOINTS NONE Muscle pain  Back pain
 Radiating pain  Joint pain  Joint swelling  Popping
8. HEM/SKIN NONE Anemia  Lumps  Rashes
 Leg ulcer  Bruising  Itching
9. NEURONONE  Memory loss  Confusion  Weakness
 Falling  Tremors  Tingling/Numbness
10. PSYCH NONE  Anxiety  Depression Insomnia
 Agitation  Hallucinations  Disoriented
11. Endoc NONE Intolerance to cold/heat  Sweating  Thirst
12. Lymph NONE Nodular swelling w/heat/ tenderness Enlarged
nodes
13. Allerg/Immun NONE WheezingSinus
pressure/dischargeHives
 Itching