Medical History Form - Free Download
This form is provided by Orthopaedic Associates.
4.9, 3182 votes
Please vote for this template if it helps you.
Medical History Form
Medical History Form 2
Name:
Weight:________ Height:________ Age:________
MR#:
________________________
Past Medical History/Review of Systems
Date:
________________________
Please check (X) the box next to any illnesses or problems that apply to you.
Cancer Asthma Tuberculosis/HIV Liver Disorder Diabetes
Alcoholism Heart Trouble Emphysema/COPD Birth Defects Heart Attack
Ulcers Kidney Disease High Blood Pressure Stroke Gout
Cholesterol Sickle Cell Anemia Bleeding Disorder Arthritis
Please Explain: _____________________________________________________________
Skeletal Health:
Other: _____________________________________________________________ History of falls/fractures Steroid
Do you smoke or drink Use
Vitamin deficiency
Do you exercise infrequently
Surgery / Fractures
Do you have a thin or petite build
Please check (X) the box next to any sur gical procedures which you have had. Have you ever had a Bone Density Test
Tonsils Breast
Appendix Uterus
Gall Bladder
Ovaries Stomach
Prostate
Small Intestine
Colon
Thyroid Kidney Hernia (repair)
Heart
Pacemaker
Joint Replacement Arthroscopy
Extremities, Neck, Back (What kind):___________________________________________________ __________________________
Any other surgeries (What kind):_________________________________________________________________________________
Allergies
Please check allergies that apply to you.
(X) the box next to any
Medications
(blood thinners, non-prescription remedies)
If you do not have allergies please check (X) none.
Name of drug and how often it is taken:
Penicillin Sulfa Metal
None
___________________________________________
___________________________________________
Other Antibiotics or other Drugs/medications ___________________________________________
What kind: ___________________________ ____________________________ _______________
___________________________________________
Any foods/cosmetics or other allergies ___________________________________________
What kind: ___________________________ ___________________________________________
Do you have any of the following Conditions
Shortness of breath Chest Pain Blurred Vision Frequent / Painful Urination
Unexpected Weight Loss
Fever / Chills Headaches Numbness in Extremities
Constipation / Diarrhea / Blood in stools
Tobacco Use
Alcohol Use:
Beer/Wine: __________ x a week
Cigarettes: Yes / No Packs/day __________ Years of use ______ Shots/Liquor: __________ x a week
Other tobacco use: ___________________________________ Other drug use: ________________ __________
Family History
Please check (X) the box next to any disease diagnosed in your blood relatives.
Cancer Diabetes Rheumatoid Arthritis Other type of arthritis
Gout Bleeding Problems Sickle Cell Anemia Heart Disease
Other: ______________________________________________________________________________________________________
Social History
Are you Single Married Divorced Widowed
Work Status: Unemployed Disabled Retired Student
Employed – Doing what _____________________________________________________________________________________________
Who lives in your house that can care for you or for whom you have to care ___________________________________________________
WHO IS YOUR PRIMARY CARE PHYSICIAN
______________________________
Sign Here: ________________________________________
PHYSICIAN NUMBER
____________________________
physician number
MEDICAL HISTORY FORM
Submit by Email
Medical History Form Previous Page
Medical History Form
Previous

1/1

Next