BHARAM - PHF

Patient History Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Preferred Name
Sex*
Gender*
For example: Cisgender woman, Cisgender man, Transgender, Nonbinary, Agender, Genderfluid, Genderqueer, Two-spirit, etc
What are your pronouns? *
She/Her; They/Them; He/Him; etc
Email*
Referred by*
(physician name, self, previous patient etc.)
Preferred Pharmacy:*
Height*
inches
Pharmacy Phone:
Weight*
pounds
What are you here for today? Please include body part and side.*
(Right/left hip, right/left groin etc.)

ALLERGIES AND SENSITIVITIES*

	Allergy	Reaction	Comments
1.
2.
3.

CURRENT MEDICATIONS*

	Medication Name	Dosage	Frequency	Comments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

REVIEW OF SYSTEMS AND PAST MEDICAL HISTORY*

	Yes	No	If yes, please specify if this a PAST OR CURRENT condition.
Alcoholism
Anesthetic complications
Arthritis
Autoimmune disease
Cancer
Clotting disorder
Deep vein thrombosis
Fractures
Gout
Heart Disease
Hepatitis C
HIV/AIDS
Hyperlipidemia
Hypertension
Infectious disease
Inflammatory arthritis
Kidney disease
Lung disease
Osteoporosis
Smoking
Stroke
Thyroid disease
Other
Other
Other
Other
Other
Other

SURGICAL HISTORY

	Name of Surgery	Date Performed	Name of Surgeon/Location
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Family History

Please indicate if anyone in your family has any of the following conditions:

	Paternal or Maternal	Mother	Father	Siblings	Other Family Member	Comments
Alcoholism
Anesthetic complications
Arthritis
Autoimmune disease
Cancer
Clotting disorder
Deep vein thrombosis
Fractures
Gout
Heart Disease
Hepatitis C
HIV/AIDS
Hyperlipidemia
Hypertension
Infectious disease
Inflammatory arthritis
Kidney disease
Lung disease
Osteoporosis
Smoking
Stroke
Thyroid disease
Other

Social History
Who is your primary care physician?*
Do you smoke? If yes, how many packs/day and how many years?*
If you quit smoking, when?
Do you drink alcohol? If yes, how much and how often?*
If you quit drinking alcohol, when?
Do you use recreational drugs?*
What is your marital status?*

MarriedSingleDivorcedWidowed
Are you pregnant?
Where were you born?*
Do you currently exercise?*
What sports or activities do you partake in? What exercise types do you participate in? *
What sports or activities did you partake in during adolescence? *
(N/A if not applicable)
Smoking History
Smoking status? Check all that apply.*

Currently an everyday smokerCurrently a someday somerFormer SmokerUnknown if ever smokedHeavy Tobacco smokerNever Smoker
Tobacco use cessation counseling? Check all that apply.*

Preganncy smoking cessation educationSmoking cessation eucationReferred to a stop-smoking clinicSmoking effects educationSmoking cessation assistanceNone
Employment History
Highest degree obtained?*
If in school, what year of school are you in?
FOR EXAMPLE: 8th grade; Freshman in College; Senior in High school; Graduate Student
Are you currently working?*
If not working, when was the last time you worked?
What is your current occupation?*
EXAMPLE: Student, social worker, finance, physician, teacher
Are you applying for disability?*
Are you currently on disability or workers compensation?*
Have you been exposed to toxins/poisonous substances at work?*
Prior Hip and Groin Treatment
Have you completed physical therapy in the past? If none, write N/A. *
Where did you have physical therapy AND what is the name and contact information (phone, email, fax)? If none, write N/A.*
For how long did you complete physical therapy? If none, write N/A.*
When did you start and end physical therapy? If none, write N/A.*
Did you previously have 1 or more injections to the hip, groin, spine, bursa and/or ? *
If yes, what injection did you get? If no, write NA.*
For example: Anesthetic, cortisone, other
If yes, what body part was injected? If no, write NA. *
For example: Right/Left hip, bursa, hamstring, spine.
What side was injected? If you did not have an injection, select N/A.*

RightLeftBilateralN/A
If yes, who performed the injection (or what facility)? If no, write NA.*
For example: Dr. XYZ at Lenox Hill Radiology, etc.
Type a question
Should be Empty:

Patient History Form

Family History

Social History

Smoking History

Employment History

Prior Hip and Groin Treatment