Patient Medical History Form

General Patient Information

Please complete entire form
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Patient Gender*
Gardian Name

First NameLast Name
Patient or Gardian E-Mail*
example@example.com
Emergency Contact

First NameLast Name
Emergency Contact number
Please enter a valid phone number.
Primary care doctor name and number( if you have one)
Patient Height *
Patient Weight *
Occupation
Reason for making appointment/ Describe how you became injured
Duration of injury*
Has your condition been getting :

WorseSameBetter
What increases pain?
What relieves pain?
Pain level 0-10 scale. ( 10 being the worst)
Patient Medical History
Please list any drug allergies
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysemaBroken Bones
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications
Healthy & Unhealthy Habits
Extra curricular activities
Exercise

Never1-2 days3-4 days5+ days
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Should be Empty:

General Patient Information

Patient Medical History

Healthy & Unhealthy Habits