General Patient History Please Complete ALL Information

Today's Date: 01/06/2009 Name: Age: DOB: Referring Doctor: Occupation: Marital Status:  Single  Married  Divorced  Widowed CHIEF COMPLAINT: Explain why are you going to see the doctor, or how the injury occurred (specify Right or Left, if applicable).

HISTORY OF PRESENT ILLNESS: How long have you had this problem?   Was this the result of an accident?    Yes    No If yes, give date:   Have you been to another doctor or hospital for this problem?    Yes    No If yes, name:  Have you had any of the following tests for this problem?  X-rays  MRI  Bone Scan  Bone Density Test  CT Scan  EMG/NCV (nerve test)  Other   Have you had any of the following treatments for this problem?  Surgery  Physical Therapy  Injections  Braces, Casts, Orthotics, or Walking Aids  Medication Name: ) How does this problem affect you? How severe is your pain?  1  2  3  4  5  6  7  8  9  10  Wakes you up at night  Interferes with work activities  Interferes with recreational activities MEDICATIONS: List all current medications, including over-the-counter drugs and diet supplements ALLERGIES: List all drug allergies PAST MEDICAL HISTORY: Please check ALL that apply CARDIOVASCULAR  Heart Attack  High Blood Pressure  Arrhythmia  Pacemaker  Heart Failure  Heart Surgery  Heart Murmur RESPIRATORY  Asthma  Bronchitis  Emphysema  Sleep Apnea GASTROINTESTINAL  Ulcers  Acid Reflux HEPATIC  Hepatitis  A  B  C  Cirrhosis  Jaundice RENAL  Kidney Stones  Urinary Tract Infection NEUROLOGIC  Stroke  TIA  Seizure  Multiple Sclerosis  Polio ENDOCRINE  Diabetes  Thyroid Disease  Hyper  Hypo  Adrenal Abnormality CANCER  List Type MUSCULOSKELETAL  Osteoarthritis  Rheumatoid Arthritis  Gout  Lupus  Osteoporosis  Other PAST SURGICAL HISTORY: List ALL surgeries FAMILY HISTORY: Please check ALL that apply  Arthritis  Heart Disease  Cancer SOCIAL HISTORY: Do you smoke?  Yes  No Drink Alcohol?  Daily  Weekly  Occasionally  Never REVIEW OF SYSTEMS: Please check ALL that apply GENERAL  Weight gain  Weight loss  Fever  Chills HEAD/NECK  Blurry vision  Sore throat  Trouble swallowing  Loss of hearing CARDIOVASCULAR  Chest pain  Skipped heart beats NEUROLOGIC  Dizziness  Numbness/Tingling  Weakness  Headaches SKIN  Unusual Rashes  Psoriasis RESPIRATORY  Shortness of breath  Sleep apnea  Cough  Wheezing GASTROINTESTINAL  Abdominal pain  Nausea/Vomiting  Diarrhea/Constipation  Bloody stools  Indigestion GENITOURINARY  Pain in urination  Unable to urinate  Involuntary urination MUSCULOSKELETAL  Joint Swelling  Morning Stiffness  Joint Pain I certify that, to the best of my knowledge, all information listed above is true. I further certify that I have not misstated or intentionally omitted any information related to my health or past medical history. Date Click checkbox to electronically sign (patient/guardian)