Bacharach Medical History Form Page 2
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2MEDICAL HISTORY FORM
Patient Identification
Please check any conditions you have:
None
Arthritis
High Blood Pressure
Within the past year, have you had any of the following tests?
Blood clots
Learning Disability
(Check those you have had; circle test(s) you are scheduled for)
Blood disorders
Low Blood Sugar
MRI
None
Broken bones/fracture
Hepatitis
Blood Tests
Eating Disorder
Kidney problems
X-rays
Circulation/Vascular
Lung Problem/Asthma
Other _____________________________________
Depression, Anxiety, Irritability
Repeated Infections
______________________________________________
Developmental Problems
Heart Problems
Emotional,behavioral problems
Other _____________
ALLERGIES
None
Please check any conditions you have and if you are
Check if you ever had the following):
under the care of a health professional for the following?
Allergies:
Medication
Food
Environmental
Latex
___ Cancer
No
___ HIV/AIDS
Yes
No
Yes
Please list all known allergies and adverse drug reactions(attach
___ Diabetes
Yes
No
separate sheet if needed)
___ Dialysis
Yes
No
___ Underweight?
Yes
____________________________________________
_______
No ___ Dysphagia
Yes
No
___ Morbid obesity
Yes
No
___ Multiple sclerosis
Yes
No
Have you had surgery or significant invasive procedures?
___ Parkinson’s Disease
Yes
No
Yes
No
___ PPN/enteral feeding
Yes
No
If yes, please describe, and indicate dates:
___ Substance abuse
Yes
No
_______________________________ _____________
___ Pressure ulcers/non-healing wounds
Yes
No
_______________________________ _____________
_______________________________ _____________
Please list your current medications and their purposes
_______________________________ _____________
(pain relief, arthritis, etc) taken for this injury/condition:
MEDICATION
PURPOSE
HEALTH HABITS
____________________
___________________
Do you exercise beyond normal daily activities and
____________________
___________________
chores?
Yes
No; Type:______________________
____________________
___________________
Do you currently smoke/chew tobacco?
Yes
No
____________________
___________________
Cigarettes/Cigars ___ # packs/day
____________________
___________________
Smoke in the past?
Yes
No; Years quit? _____
____________________
___________________
List all other medications/purposes:
(including over-the-
)
counter medications, vitamins, and herbs
EDUCATION/EMPLOYMENT
____________________
___________________
Highest grade completed (circle one)
____________________
___________________
1 2 3 4 5 6 7 8 9 10 11 12
____________________
___________________
College/Technical School/Vocational School
Not taking any medication for this problem/injury
College Graduate
Advanced/Graduate Degree
Your occupation?_______________________________
Leisure interests:_______________________________
Within the past year, have you had any of the following
symptoms? (Check all that apply)
None
Method you learn best:
Watching
Listening
Back/Neck Pain
Hearing Problems
Doing
Having written information
Bowel Problems
Hoarseness
Chest Pain
Joint Pain/Swelling
CULTURAL/RELIGIOUS: Do you have any customs,
Coordination Problem
Loss of Appetite
religious beliefs, or wishes that might affect care?
Cough
Loss of Balance
______________________________________________
Communication problem
Nausea/Vomiting
None
Difficulty Sleeping
Pain at Night
Difficulty Swallowing
Shortness of Breath
ABUSE SCREENING
Do you have any concerns about physical, emotional, or
Difficulty Walking
Urinary Problems
Dizziness/Blackouts
Vision Problems
sexual abuse?
Yes
No
Would you like to talk to someone about your situation?
Fever/Chills/Sweats
Weakness
/Arms/Legs
Yes
No
Headaches
Weight Loss/Gain
Heart Palpitations
Other ___________
Are you seeing anyone else for this problem?
Acupuncturist
None
(check all that apply)
Cardiologist
Orthopedist
Chiropractor
Osteopath
Dentist
Massage Therapist
Podiatrist
Internist
Rheumatologist
Neurologist
ENT
Primary Care Doctor
Pediatrician
Obstetrician/Gynecologist
Occupational Therapist
Other: _______________________
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