Medical History Worksheet

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MEDICAL HISTORY WORKSHEET
Please briefly tell us about your current problem or injury:
Please describe the reason we are seeing you
today: _______________________________________________________
When did your first symptoms appear? (Provide the date if known) ________________________________
Is this a Workers' Compensation Injury/Claim? No  Yes 
Is this a result of a motor vehicle accident? No  Yes 
What were you doing when the first symptoms appeared? ______________________________________
Would you describe your current pain as: mild  moderate  severe  no pain 
How many hours a day are your symptoms present? 2-4 hrs 4-8 hrs 8-12 hrs >12 hrs
What makes your symptoms worse? ________________________________________________________
What makes your symptoms better? ________________________________________________________
Please tell us about your health:
Please circle any serious illnesses you have now or have had in the past:
ADD/ADHD
Coronary Artery Disease
Hypothyroidism
Anxiety/Depression
Prior MI/Heart Attack
MRSA Infection
Fibromyalgia
Hypertension
Tuberculosis
Gout/Pseudogout
Pacemaker/AICD
Kidney Disease
Lupus
MVP/Valve Disease
Kidney Failure/Dialysis
Osteoarthritis
Chronic Anemia/Blood Disorder
Latex Allergy
Psoriatic Arthritis
Chronic Leg or Foot Ulcers
Liver Disease/Hepatitis
Rheumatoid Arthritis
Chronic Migraines
Lymphedema
Mixed Connective Tissue Dz
Chronic Urinary Tract
Metal Sensitivity
Infections/UTI’s
Unspecified Arthritis
Diabetes - Diet Controlled
Osteoporosis/Osteopenia
Asthma/COPD/Emphysema
Diabetes - Non-Insulin
Seizure Disorder/Epilepsy
Dependent
Bleeding Disorder
Diabetes – Insulin Dependent
Sleep Apnea
Blood Clots/DVT’s
Ulcers/Bleeding Ulcers
Stroke and/or TIA’s
History of Pulmonary Embolism
GERD/Reflux
Tetanus Vaccination
Cancer type:
Hernia
Peripheral Arterial Disease
Arrhythmia/Palpitations
High Cholesterol
Venous Insufficiency
CHF/Heart Failure
HIV / AIDS
Anything Else?
Please list all of your previous surg

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