Name: ____________________________________ _
Primary Care Dr. _________________________
Age: _____
Height: _____
Weight: _____
Doctor who referred you to us? ____________________
Reason for Today’s visit? _____________________________________________________________________
Date of Injury or Onset of pain? ____/____/_______
Gradual Onset,
Long standing problem ___Mo. ___Yrs
Where Did This Occur? (Circle)
Motor Vehicle Accident,
Have X-rays been taken? (Circle) YES NO
Past Medical History
Anemia
Asthma
Work Accident,
Sports Injury,
Do you have them with you? YES
No Injury,
NO
(Circle all illnesses that you have now or have had in the past)
Cancer
Diabetes
Emphysema (COPD)
Heart Disease Hernia
Heart Murmur Hepatitis
Hypertension
Kidney Dz.
Polio
Seizures
Gout
Other:_______
Ulcers
Allergies
_______________
_______________
_______________
_______________
_______________
_______________
_______________
Medications
Dose
Stroke
_________________
_______________
Prior Surgeries
_____________________ _____________
_____________________ _____________
_____________________ _____________
_____________________ _____________
_____________________ _____________
_____________________ _____________
_____________________ _____________
_____________________ _____________
_____________________ _____________
__________________
_________
Thyroid Dz.
Year
____________________________
_____
____________________________
_____
____________________________
_____
____________________________
_____
____________________________
_____
____________________________
______
Review of Systems
Are you Currently having problems with:
Headaches
Eyes or Vision trouble
Ears or Hearing
Frequent Sinus Infection
Bleeding Gums/ Ulcers
Difficulty Swallowing
Lungs or Breathing
Chest Pain /Palpitations
Blackout/ fainting
Digestion problems
Upset Stomach/Pain
Black or Bloody Stools
Bladder Problems
Easy Bleeding /Bruising
Balance Problems
Numbness/Tingling
Depression or anxiety
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__YES
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
__NO
Describe Positive Responses
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Patient Signature: _____________________________
Date: ____________
Reviewed By __________________________ M.D.
Date _______________
This Form To Remain On Top Of Section
Social History (circle all that apply)
Presently Employed? NO
Work in the home
Student
Retired
Disabled
YES Occupation __________________ Fulltime
Part-time
I am Currently:
Married
Single
Divorced
Widowed
Any Children?
NO
YES #________
Do you live alone? NO
YES
Exercise Frequency? DAILY
WEEKLY
MONTHLY RARELY
NEVER
Type of exercise? ____________________________________________________________
Tobacco Use?
NONE
CIGARRETTES
CIGARS
DIP
Present Usage?
___ Pack per day for ____ years
Quit Smoking?
THIS YEAR >1 YEAR
>5 YEARS >10 YEARS
Substance Abuse?
NO
YES What? ________________________________________
Alcohol Use?
NONE
DAILY
2-4 x/ WEEK 2-4x/ MONTH
RARELY
Family History
Grandmother
A / D
_________________
Grandfather
A / D
________________
_
Grandmother
A / D
__________________
Grandfather
A / D
________________
_
Mother
Father
A / D
A / D
Brother/ Sister
A / D
Brother/ Sister
A / D
YOU
Circle A = Alive D = Deceased
Write Health Status or Cause of Death In Each Box
(e.g. Good Health, Cancer, Diabetes, High Blood
pressure, Heart Attack, Alzheimers, etc.)
Brother/ Sister
A / D
Brother/ Sister
A / D
Brother/ Sister
A / D
Brother/ Sister
A / D
Orthopaedic Screen (circle any conditions you have now or in the past)
Back Pain
Ruptured Discs
Sciatica
Scoliosis
Bursitis
Fractures
Frequent Sprains
Dislocations
Tumors
Other: ____________ _________________ ________________
Tendinitis
Osteoporosis Bone Infections Gout
PhysicianNotes:_______________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Patient Signature: _____________________________
Reviewed By __________________________ M.D.
Date: ____________
Date: ____________