Medical History printable pdf download

Medical History

MEDICAL HISTORY for _________________________________________________________ Date ______________

Welcome to our orthopaedic practice. We would appreciate your thoughtful and careful completion of

the following information. Please be sure to bring with you the completed form. Thank you.

Who is your Primary Care Doctor? _____________________________________________________________________

Do you wish that this office to send him/her a report of your visit today?

Yes, please

Not necessary, thank you

CHIEF COMPLAINT and HISTORY OF PRESENT ILLNESS

If this is an INJURY:

Give the date of injury ___________________ and time, if known ____________________

Where did this injury occur?

At work

Car Accident

At home

Other place: _________________________________________________________

Describe the nature of the injury and include whether it is right or left-sided.

How did this injury occur?

Did you receive any previous treatment for this injury?

YES - Please describe:

If this is NOT an injury:

What was the nature of your complaint that brought you into our office to see the doctor?

Where is your pain or other symptoms apparent? Include whether it is right or left-sided.

How long have you been bothered by this complaint?

YES – Please describe:

Have you had any previous treatment for this complaint?

PLEASE SIGN:

I hereby verify the above information to be correct

X_____________________________________________________

Medical History