Medical History Form
ADVERTISEMENT
1
2Return to Menu
Chart#:_________
Medical History Form
(Please use black ink)
Patient Name:__________________________________________ Appointment Date:_______________ with Dr. _________________________
Age:__________ Sex:
F
M Height: ________ Weight:________
Dominant hand:
R
L Did you bring X-rays?
Y
N
Who is your primary physician? (name): ____________________________________
MD
PA Clinic Name? ______________________
_________________________
What is the reason for this visit?
Pain
Numbness
Weakness
Swelling
Stiffness
Other
Latex Allergy?
Y
N
_______________________________________________________________
What body part is involved? (Please mark the table below)
Shoulder
E l b o w
W r i s t
H a n d
H i p
K n e e
A n k l e
F o o t
N e c k
B a c k
R
L
R
L
R
L
R
L
R
L
R
L
R
L
R
L
How long ago did it start?______ Days______Weeks______Months______Years.
Have you had a problem like this before?
Y
N
In this section, check the ONE BOX which best describes how your problem started. Then answer the questions below the box you
checked. Use as much space to the right as needed.
NO INJURY (or onset was:
Gradual or
Sudden)
COMMENTS:
Please indicate why do you think it started?
INJURY (
Accident
Sport ( NOT Auto or Work)
Date:__________ Please specify where and how it happened.
What Sport?________________ School?________________
INJURY AT WORK
Date:____________________
From a:
lift
twist
fall
bend
pull
reach
WORK RELATED (BUT NO INJURY)
Date:_______________ How did your job cause the problem?
AUTO ACCIDENT Date:_________ How was your car hit?
On a scale of 0 – 10 (10 is the worst) how severe is your pain? (circle)
0 1 2 3 4 5 6 7 8 9 10
What is the quality of the pain?
Sharp
Dull
Stabbing
Throbbing
Aching
Burning
The pain is:
Constant
Comes and goes (intermittent).
Does your pain wake you from your sleep?
Y
N
Do you have:
Swelling
Bruises
Numbness
Tingling
Weakness
Loss of control of bowel or bladder
Locking/Catching
Giving way
Since my problem started, it is:
Getting better
Getting worse
Unchanged
What makes your symptoms worse?
Standing
Walking
Lifting
Exercise
Twisting
Lying in bed
Bending
Squatting
Kneeling
Stairs
Sitting
Coughing
Sneezing
Which make your symptoms better?
Rest
Elevation
Ice
Heat
Other: _________________________________________
What medications are you taking now?
___
ALLERGIC TO ANY MEDICATIONS?
Y
N if yes please list and describe reaction:________________________________
Have you had any of these treatments? Injection:
Y
N
Brace:
Y
N
Physical Therapy:
Y
N
Cane/Crutch:
Y
N
Were you seen in the E.R. for this problem?
N
Y Which E.R.?___________________Date:______________________________
Are you here today as a result of an E.R. Visit?
N
Y Who saw you in E.R.?___________________________
MD
PA
What test/scans have you had for this problem?
X-Rays
MRI
CAT Scan
Bone Scan
Nerve Test (EMG/NCV)
Where?_________________________________________
Have you already had surgery for a problem in this same area either recently or in the past?
N
Y
Please list below:
Procedure #1________________________Surgeon___________________________City_____________________Date___________________
Procedure #2________________________Surgeon___________________________City_____________________Date___________________
Current work status?
Regular
Light duty - (how long?________________ )
Not working due to this problem
Disabled
Retired
Student
When is the last date you worked your regular job?_______________________________________________________________________________
Are you currently receiving or plan to apply for: Disability:
Y
N
Worker’s Comp:
Y
N
Unemployment:
Y
N
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical