Medical History And Pain Assessment Form

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MONADNOCK ORTHOPAEDIC ASSOCIATES
YOUR NAME _____________________________________ TODAYS DATE: ____________________
You are asked to complete this form in FULL if you are new to the practice or update your form if it has
been over 6 months since your last visit. ALL information is confidential &VERY important to your care.
THANK YOU FOR CHOOSING M.O.A.!
Personal Medical History:
Condition:
Yes √
No √
Yes
No
Heart Problems (what type?)
High Blood Pressure
Stroke/ TIA
Sugar Diabetes Type I or II
Neurological Problems
Thyroid Problems
Epilepsy/ Seizures
Osteoporosis/ Thin Bones
Stomach Ulcers
Osteoarthritis or Rheumatoid Arthritis
Gastric Reflux (GERD)
Metal in body? Pacemaker?
CANCER (type?)
Problems with Anesthesia (what?)
Hepatitis A, B, C/Liver Disease
Lung Problems/ COPD/ Asthma
Kidney Problems (type?)
Sleep Apnea
Anxiety or Depression
Cholesterol
Other Medical Conditions: (List)
Blood/Bleeding Disorder
Family Medical History: Father (Alive or Deceased?) Age ____ Mother (Alive or Deceased?) Age ____
Condition:
Yes √
No√
Yes √
No √
Who?
Who?
Heart Problems (what type?)
High Blood Pressure
Stroke/ TIA
Sugar Diabetes Type I or II
Neurological Problems
Thyroid Problems
Epilepsy/ Seizures
Osteoporosis/ Thin Bones
Stomach Ulcers
Osteoarthritis
Gastric Reflux (GERD)
Rheumatoid (Inflammatory) Arthritis
CANCER (type?)
Total Joint Replacement
Hepatitis A, B, C/Liver Disease
Lung Problems/ COPD /Asthma
Kidney Problems
Problems with Anesthesia
Anxiety or Depression
Sleep Apnea
Blood/Bleeding Disorder
Other Familial Medical Conditions: (List)
Social History:
Your Occupation:
Highest Education Level:
Live alone or with others?
Alcohol intake? (amount)
Single/ Married/ Divorced?
Tobacco History?Packs per day _____ years ____
Stairs at home?
Do you still smoke? ______ When Quit?________
Leisure/Sporting Activities?
Recreational Drug use? Yes/ No
Medical History Form – Page 1 of 2

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