Patient Medical History Form |
| **Please note: We realize the following form is very detailed. However, failure to provide all information requested may result in numerous phone calls from our staff and a delay in scheduling appointments.***
To navigate use your mouse, or the TAB key (do not use the Enter key) |
| PATIENT INFORMATION |
| First Name |
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M.I. |
(Middle Initial) |
| Last Name |
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Date of Birth |
(mm/dd/yyyy) |
| Sex |
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Age |
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| Height |
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Weight |
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| E-mail address |
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INJURY & TREATMENT INFORMATION |
| Primary Care Physician |
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Doctor's Phone Number |
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| Occupation |
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Employer |
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| List body part to be seen |
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| Injuries (indicate if on-the-job or MVA) |
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| Date of Injury |
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| Treatment before arrival? |
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| Allergies to medicine?
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| Medication (please include dose/frequency) |
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PHYSICAL INFORMATION |
Do you use:
Aspirin
Tobacco
Packs Per Day
Quit?
Alcohol
Glasses Per Day
Per Week
Recreational Drugs
If yes, please list below |
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| Surgeries, Hospitalizations, Births or Illnesses (include dates) |
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| Family History (Cancer, stroke, heart disease) |
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DO YOU HAVE OR HAVE YOU EVER HAD: |
| Have you ever been diagnosed with or exposed to a MRSA infection? |
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| Do you have a personal/family history of DVT (Blood clots)? |
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| Eye, ear, nose, throat problems (Examples: glaucoma, lens implants, dentures, difficulty hearing, wear hearing aids, glasses or contacts) |
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| Heart problems (Examples: chest pain, angina, heart attack, congestive heart failure, irregular heart beats, pacemaker) |
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| Vascular problems (Examples: high blood pressure, blood clots) |
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| Lung problems (Examples: asthma, emphysema, tuberculosis, coughing, coughing blood, abnormal chest x-ray, sleep apnea) |
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| Gastrointestinal problems (Examples: hepatitis, cirrhosis, ulcers, reflux, hiatal hernia, intestinal bleeding, heartburn) |
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| Is there any possibility you could be pregnant? |
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| Musculoskeletal problems (Examples: back problems, broken bones, gout, limited range of motion, arthiritis, TMJ) |
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| Skin problems (Examples: rash, hives, bruise easily, open sores) |
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| Neurological problems (Examples: seizures, paralysis/numb areas, stroke, weakness, migraines, confusion, dizziness) |
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| Psychiatric care (Examples: anxiety, depression, bipolar disorder) |
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| Endocrine problems (Examples: diabetes, thyroid, weight gain/loss) If diabetic, controlled by: diet, oral agent, or insulin? |
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| Blood disorders (Examples: anemia, unusual bleeding problems, HIV, high cholesterol) |
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| Cancer |
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| A bad reaction to anesthesia? |
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| Hobbies |
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WHERE/HOW DID YOU HEAR ABOUT US? |
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Other:
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PATIENT AGREEMENT
, and I agree to the Oregon Orthopedic & Sports Medicine Clinic Privacy Practices.
Please click Send button only once
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Optional Printable Patient Medical History Form (writable PDF)
