Patient History



DemographicsPart 1 of 9
Male Female *

Yes No

* Employer Information
Employed Self Employed Retired Unemployed Disabled Student
* Insurance Information


* Pharmacy Information
No preferred Pharmacy
* Provider Information
No Primary Care Provider



Reason For VisitPart 2 of 9
Left Right
Yes No

* MedicationsPart 3 of 9
* Allergies

Current Treatment for ConditionPart 4 of 9
Tylenol
Ibuprofen
Prescription Medication
Aleve
Another NSAID
Other
Ice
Brace



Work
Sleep
Daily Activities
Exercise



Previous TreatmentPart 5 of 9
Yes No

Yes No
Yes No


Yes No


Yes No


Yes No


Yes No
Right Left Both

Patient Medical HistoryPart 6 of 9
Alzheimers disease
Anemia
Angina
Arthritis
Asthma
Cancer
Congestive heart failure CHF
COPD
Coronary artery disease CAD
Crohns disease
Deep venous thrombosis DVT
Degenerative joint disease
Depression
Diabetes
Drug Abuse
Elevated lipids
Fibromyalgia
Fracture
Gout
Headache migraine
Heart Attack
Heart rhythm issues
Heart valve issues
Hepatitis liver disease
Hypertension
Inflammatory bowel disease
Lyme disease
Malignant hyperthermia
Obesity
Osteoporosis
Parkinson disease
Pepticulcer disease
Psoriasis
Renal disease
Rheumatoid arthritis
Scoliosis
Seizure disorder
Sleep apnea
Spinal stenosis
Spondyloarthopathy
Stroke
Systemic lupus erthematosus
Thyroid disease


Yes No
Yes No

Surgical HistoryPart 7 of 9

ACL repair
Amputation
Angioplasty
Appendectomy
Arthroscopy
Back surgery
Blood transfusion
CABG
Cardiac pacemaker
Cardiac valve replacement
Carpal tunnel release
Cataract extraction
Cholecystectomy
Colectomy
Colostomy
Gastric bypass
Hernia repair
Hip arthroplasty
Hip replacement
Knee replacement
LASIK
Meniscus surgery
ORIF
Rotator cuff repair
Small bowel resection
Thyroidectomy
Tonsillectomy

Yes No

Yes No


Yes No



Family HistoryPart 8 of 9
ADD ADHD
Alcoholism
Allergies
Alzhemimers disease
Anemia
Arthritis
Asthma
Blood disorder
Cancer
Cardiovascular disease
Colitis
Congenital heart disease
Congestive heart failure
COPD
Coronary artery disease
Coronary artery disease premature
Depression
Developmental delay
Diabetes
Drug abuse
Elevated lipids
Genetic disease
Gout
Hearing impairment
Heart disease or attack
Heart rhythm issues
Hypertension
Learning disability
Liver disease
Malignant hyperthermia
Mental illness
Migraines
Muscle disease
Obesity
Osteoporosis
Parkinsons disease
Peripheral vascular disease
Renal disease
Rheumatoid arthritis
Seizure disorder
Stroke
Thyroid disorder





Social HistoryPart 9 of 9
Yes No
Cigarettes
Cigars
Chew Tobacco
Snuff
Cigarillo
Pipe Tobacco
Smokeless
Yes No
Yes No
Yes No
Beer
Wine
Liquor
Daily
Weekly
Monthly
Socially
Occasionally
Rarely
Yes No
Yes No
Energy Drinks
Coffee
Soda
Tea