Patient Intake Form Orthopedic Specialty Institute Page 2
ADVERTISEMENT
1
2
3
44) Do
y ou
h ave
a ny
a llergies
t o
a ny
m edications?
Yes
No
If
y es,
p lease
l ist
a nd
g ive
y our
r eaction
y ou
g et
t o
t he
m edication:
_____________________________________________________________________________________
5) Are
y ou
a llergic
t o
L atex
o r
T ape?
Yes
No
6) Have
y ou
e ver
h ad
M RSA?
Yes
No
7) Are
y ou
c urrently
o r
h ave
y ou
e ver
h ad
p roblems
w ith
t he
f ollowing:
Y
N
Y
N
No
P ast
M edical
P roblems
R eported
Liver
D isease
Anxiety
D isorder
Low
B ack
P ain
Arthritis:
W hat
K ind:__________________
Neck
P ain
Asthma
Mid
B ack
P ain
Bleeding
D isorder
Radiculopathy
–
U pper
Blood
C lots
( Deep
V ein
T hrombosis)
Radiculopathy
–
L ower
Cancer:
W hat
K ind:___________________
Organ
T ransplant
CHF
Osteopenia
Claustrophobic
Osteoporosis
Coronary
A rtery
D isease
Other
L ung
D isease
COPD
Poliomyelitis
Diabetes
T ype
I
Peripheral
V ascular
P roblem
Diabetes
T ype
I I
Pulmonary
E mbolism
Dialysis
Reflux
D isease
Diverticulitis
Rheumatoid
A rthritis
Fibromyalgia
Sciatica
Gout
Stroke
Pacemaker
Tuberculosis
( TB)
Heart
A rrhythmia
Ulcers
Heart
A ttach
( MI)
Urinary
T ract
I nfection
Heart
M urmur
Other:
Hiatal
H ernia
Problems
w ith
A nesthesia
HIV
o r
A IDS
Hepatitis
Hypertension
Hypercholesterolemia
Hyperthyroidism
IBS
( Irritable
B owel
S yndrome)
Kidney
D isease
Kidney
S tones
Leg/Foot
U lcers
8) Please
l ist
a ll
p ast
s urgeries
a nd
h ospitalizations:
S urgery/Hospitalization
Date
Physician
9) Have
y ou
e ver
h ad
p roblems
w ith
g eneral
a nesthesia?
YES
NO
10) Do
y ou
d rink
a lcohol?
YES
NO
If
y es,
h ow
m uch
p er
w eek?
11) Do
y ou
s moke?
YES
NO
If
y es,
h ow
m uch
p er
w eek?
If
y es,
h ow
l ong
h ave
y ou
s moked?
Patient
N ame:
Page
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business