ORTHOPEDICS PATIENT HEALTH HISTORY
In order for us to obtain a complete medical history, it is important for you to fill out this form as completely as possible.
Please fill out every item. It is important for your doctor to know that you have carefully reviewed every area of this
form. This information will be entered into the computer and you are welcomed to a copy of the report if you wish.
Full Name _________________________________ Male
Female
Age_______
Date of Birth ________________
Height_______ Weight_______ Pharmacy Preference (include location) ________________________________________________
Primary Care Physician ____________________________
Referring Physician (if different)______________________________
(TAB 1) Are you taking ANY kind of medication now? (This includes prescription, over-the-counter or herbal medications)
No
Yes If yes, please list below include dosages.
Dosage
Medication Name
(TAB 2) ARE YOU ALLERGIC TO ANY MEDICATIONS?
Name of Medication
No
How often taken
Yes If yes, please list below.
Type of Reaction
(TAB 3) Are you allergic to contrast dye?
No
Yes If yes, what reaction do you have?_______________________
Are you allergic to any non-medical things such as latex, tape, metal?
No
Yes
latex
tape
metal
(TAB 4) Have you ever been DIAGNOSED with any of the following problems?
Cancer:
bone
breast lung lymphoma
prostate
multiple myeloma
other______________
Heart and Blood Vessels:
High / Elevated Cholesterol
No
Yes What year?_________
High Blood pressure
Congestive Heart Failure
Lungs and Respiratory:
Asthma
COPD/Emphysema
Tuberculosis
Stomach and Digestive:
GERD
Duodenal ulcer
Hepatitis
Stomach ulcer
No
No
Yes What year?_________
Yes What year?_________
No
No
No
Yes What year?_________
Yes What year?_________
Yes What year?_________
No
No
No
No
Yes What year?_________
Yes What year?_________
Yes What year?_________
Yes What year?_________
Kidney and Gender Problems:
Renal failure
No
Are you pregnant?
No
Mental & Emotional:
Depression
No
Anxiety
No
Glands, Hormones, and Sugar Control:
Diabetes
No
Thyroid deficiency
No
Thyroid excess
No
Blood & Lymph Node problems:
Anemia
No
Yes What year?_________
Yes What year?_________
Yes What year?_________
Yes What year?_________
Yes What year?_________
Yes What year?_________
Yes What year?_________
Yes What year?_________
Allergies, Immune & Infectious Problems:
HIV
No
Yes What year?_________
Infectious mononucleosis
No
Yes What year?_________
(TAB 5) SURGERIES AND HOSPITALIZATIONS
Have you had any surgeries?
No
Yes
Please list any surgeries and when they were done ___________________________________________________________________
____________________________________________________________________________________________________________
Have had problems with anesthesia (being numbed or put to sleep)?
high fever trouble with intubation (placement of breathing tube
PLEASE COMPLETE OTHER SIDE
(TAB 8) FAMILY HISTORY
Specific Anesthesia Problem
Heart and Blood Vessels:
Heart Disease
High Blood Pressure
Lungs and Respiratory:
Asthma
Lung Cancer
Mother
Father
Brother
Mother
Mother
Father
Father
Brother
Brother
Mother
Mother
Father
Father
Sister
Brother
Brother
Sister
Sister
Brain and Nervous:
Stroke
Mother Father
Glands, Hormones, and Sugar Control:
Diabetes
Mother Father
Sister
Sister
Blood & Lymph Node problems:
Bleeding/clotting problem Mother
Other________________ Mother
(TAB 9) SOCIAL HISTORY
What is or was your occupation? __________________________________________
Have you ever used tobacco in any form?
If yes, please complete the following:
Type of Tobacco
Cigarettes per day: ________
Other: (list type) __________
Are you currently using tobacco?
Which is your dominant hand?
Exercise level:
None
Living setting: Alone
Assisted living
No
Yes
No
Sister
Brother
Sister
Brother
Brother
Sister
Sister
Check here if you are retired.
Do you consume alcohol?
No
Yes
If yes, please complete the following:
How
Type of Alcohol
Much
How often
Yes
Right
Left
Regularly 1-2 times/wk
Father
Father
Brother
Neither is dominant (ambidextrous)
Regularly 3 or more times/wk 20 mins
Spouse
Children
other________________
Mother
Father
other_____________________
Nursing Home
(TAB 10) REVIEW OF SYSTEMS:
Have you recently had any of the following medical problems? CHECK yes or no and any of the following you have had.
General Health Problems
fever
chills
excessive fatigue
Head, Face, Eye, Ear problems
headache
face pain
blurred vision
double vision
hearing loss
dizziness
No
weight loss
Yes
No
Yes
loss of vision
ringing
Stomach problems
abdominal pain
reflux
diarrhea
nausea
Urninary problems
recurrent infections
pain with urination
No
difficulty urinating
incontinence
No
Yes
painful joints
stiffness
decreased motion
Mouth & Throat problems
change in voice
snoring
ulcers
No
sore throat
Yes
Bones, Joints and Muscles
pain in back
swelling of joints
Neck problems
neck masses or lumps
No
swollen glands
Yes
Brain or Nervous system problems
change in alertness
numbness
seizures
pain
Heart or circulation problems
No
Yes
chest pain
irregular heartbeat
heart murmur
shortness of breath
swelling of ankles
blacking out or fainting
leg cramps
bluish discoloration of lips or fingernails
Lung or respiratory problems
chronic cough
wheezing
frequent upper respiratory infections
No
Yes
No
Yes
heartburn
vomiting
No
unsteady gait
weakness
Yes
Yes
Problems with Glands, Hormones
No
Yes
heat or cold intolerance
unwanted weight change
excessive thirst or urination
Problems with Blood or Lymph nodes
No
bleeds excessively after injury
bruises easily
anemia
Yes