Ions Medical History Form

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BP______/______
P______________
O2 Sat_________
IONS Medical History Form
Patient Name: _____________________________________________DOB:_ ___/____/____ Age: _______ Height: ________ Weight: ________
Primary Care Physician: _______________________ Referring Physician: _____________________ Pain Management: __________________
Please list your Allergies and the reaction to the med: __________________________________________________________________________
________________________________________________________________________________________________________________________
Medications: (PLEASE LIST ALL CURRENT MEDICATIONS AND DOSAGES): ________________________________________________
______________________________________ _________________________________________ _____________________________________
______________________________________ _________________________________________ _____________________________________
Preferred Pharmacy: (please list name and intersection of pharmacy) ____________________________________________________________
Patient Past Medical History: PLEASE CHECK ALL THAT APPLY TO YOU OR □ N/A
Hypertension
Hepatitis
Stroke
Asthma
COPD
Migraines
Aids/HIV
Cancer
Obesity
Alcoholism
Depression
Osteoarthritis
Allergies
Diabetes
Osteoporosis
Alzheimer’s /Dementia
Heart Disease
Renal/Kidney Disease
Blood Disease
Other
Seizure Disorder
Chief Complaint: What body part are we seeing you for? LEFT or RIGHT _________________________________________________________
Was this work related? YES / NO Was this due to a motor vehicle accident?
YES / NO
Date of Onset / Injury: _________________
How/Where did you get hurt? _______________________________________________________________________________________________
Have you had any X-rays, MRI’s or CT’s related to the above problem? Yes / No
Where?____________________________________________
Please rate your pain at its BEST
Please rate your pain at its WORST
on a scale of 0-10 (0=NO pain, 10=Extreme pain):
on a scale of 0-10 (0=NO pain, 10=Extreme pain):
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
Circle the word(s) that best describe your pain:
Radiating / Aching / Burning / Dull / Piercing / Sharp / Throbbing / Other________________________________________________________
What makes your pain WORSE?:
Bending / Stairs / Lifting / Movement / Pushing / Sitting /
Standing /
Walking /
Other__________________________________________
What makes your pain BETTER?:
Brace / Elevation / Exercise / Heat / Ice / Massage / Medication(s) / Movement / Therapy / Rest /
Stretching / Other_____________________________

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