Medical History And Pain Assessment Form Page 2
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2MONADNOCK ORTHOPAEDIC ASSOCIATES
Surgical History: (please CIRCLE and DATE)
Tonsils/ Adenoids
Nasal/ Oral
Appendix
Tubes/ Vasectomy
Gallbladder
Bladder Suspension
Hysterectomy/Ovaries
Prostate Removal
Cardiac Surgery: (List)
Lung Surgery: (List)
Vascular: Stent/ Artery Bypass/ Vein Stripping
Major Abdominal: Liver/ Kidney/ Bowel
Hernia Repair
Plastic Surgery: (List)
Cancer Surgery
Prior anesthetic reactions?
Other Surgery: (List)
Orthopaedic Conditions:
Type/Date/Age/Complications?
Fractures
Injuries
Joint Replacements
Other:
Medications: (List name and dose or provide copy of medication list to the MD/Nurse)
Supplements/vitamins?
Over the counters?
DO YOU HAVE MEDICATION OR DRUG ALLERGIES? Rash/Hives/Breathing problem/Nausea?
NO/ YES (list) _______________________________________________________________________
_______________________________________________________________________
DO YOU HAVE ANY OF THESE PROBLEMS? Elaborate whenever possible
Symptom:
Yes √
No√
Yes √
No √
Appetite/Weight loss
Abnormal Lymph Nodes
Poor sleep (why?)
Chest Pains
Breathing Difficultly
Uncorrected Vision Problems
Blood Condition (what?)
Skin Conditions (what?)
Bladder Problems (what?)
Morning Stiffness (where?)
Bowel Problems (what?)
Food Allergies (what?)
Night Sweats or Chills
Immunity Problems (what?)
Unexplained Fevers
Bruising or Clotting Problems
Dizziness or Poor Balance
Currently Depressed
Problems with Anxiety
Other Joint or Muscle problems: (List)
Provider Signature_________________________________ Date reviewed ____________
Medical History Form – Page 2 of 2
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