WDM - Patient History Please Complete ALL Information

Today's Date: Name: Sex: Age: Occupation: D.O.B.: Referring Doctor: If student, name of school:   Marital Status:    Single    Married    Divorced    Widowed CHIEF COMPLAINT: Explain why are you here to see the doctor, or how the injury occurred.

HISTORY OF PRESENT ILLNESS: Did injury occur on the job?    Yes    No Date of injury:   Were you seen in the emergency room?    Yes    No Name of hospital/clinic:  Date:   Were X-rays taken?    Yes    No Tests taken:  X-rays  MRI  Bone Scan  Bone Density Test  CT Scan  EMG/NCV (nerve test)  Other   Has this problem been evaluated by another doctor?    Yes    No Name of doctor:    Date:  Have you had any of the following treatments for this problem?  Surgery  Physical Therapy  Injections  Braces  Casts   Have you ever had a reaction to anesthesia?    Yes    No 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  Heart Attack  High Blood Pressure  Irregular heart beat  Pacemaker  Heart Failure  Diabetes  Thyroid problems  Adrenal problems  Ulcers  Acid Reflux  Asthma  Bronchitis  Emphysema  Sleep apnea  Hepatitis  Cirrhosis  Jaundice  Pancreatitis  Osteoarthritis  Rheumatoid arthritis  Gout  Lupus  Osteoporosis  Kidney Stones  Urinary tract infections  Stroke  TIA  Seizure  Multiple sclerosis  Polio  HIV/AIDS  Tuberculosis  Cancer history: (please list) Are you in remission?  Yes  No SOCIAL HISTORY: Have you ever smoked?    Yes    No If so:   How many years?   Packs per day?   Are you smoking now?  Yes    No Do you drink?    Yes   If so, how often?    Daily  Weekly  Occasionally REVIEW OF SYMPTOMS: Please check ALL that apply  Weight gain or loss  Headaches  Nausea or vomiting  Sore throat  Sleep apnea  Pain with urination  Numbness or tingling  Abnormal bleeding  Weakness  Abdominal pain  Blurry vision  Shortness of breath  Indigestion  Dizziness  Chest pain  Skipped heart beats  Chills  Psoriasis  Bloody stools  Loss of hearing  Wheezing  Joint pain  Fever  Unusual rash  Diarrhea/constipation  Trouble swallowing  Cough  Involutary urination  Joint swelling PAST SURGICAL HISTORY: List ALL surgeries. 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)