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New Patient Medical History
Patient Name:
*
Full legal name
Date of Birth
*
/
Month
/
Day
Year
Date
Height:
*
Feet & Inches
Weight:
*
In pounds
Hand Dominance:
Right
Left
Ambidextrious
Preferred Language:
*
English
Spanish
Korean
Other
Preferred Pharmacy:
Pharmacy Phone:
If unknown, leave blank
Primary Care Physician:
How did you hear about us?
Physician Referral
Emergency Room (Northside Forsyth)
Emergency Room (Northside Duluth)
Emergency Room (Other)
Urgent Care
Friend/Family Member
Employee
Online Search
Website
Social Media
Other
Who may we thank for the referral?
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Please select the primary reason for your visit today:
*
Rows
Right
Left
Bilateral
Shoulder
Upper Arm
Elbow
Wrist
Hand
Hip:
Thigh:
Knee:
Lower Leg:
Ankle:
Foot:
Neck
Mid-Back
Lower-Back
Is this due to an injury?
*
Yes
No
Date of injury:
/
Month
/
Day
Year
If unknown, estimate the closest date.
Please explain how the injury occurred.
Please provide a brief description
If no injury, how long have you had this problem?
(Estimate # days, weeks, months, years)
Is this problem due to a work-related injury or worker's compensation claim?
*
Yes
No
Employer:
*
In this problem due to a Motor Vehicle Accident? (Collisions involving cars, trucks, motorcycles, etc. that may or may not involve another vehicle)
*
Yes
No
Date of accident:
/
Month
/
Day
Year
Date
Has an auto insurance claim been filed?
Yes, with personal vehicle insurance
Yes, with someone else's vehicle insurance
No, but planning to file
No claim filed
Are you currently represented by an attorney?
*
Yes
No
Name of representative and firm:
Have you been treated for this problem in the Emergency Room or Urgent Care?
*
Yes
No
In which hospital were you seen?
Example: Gwinnett Medical Center, Northside Forsyth, etc.
Have you been treated for this problem by another doctor?
*
Yes
No
What is the name of the doctor who treated you?
Please include practice or facility name if possible.
Have you had any of the following tests for your current problem?
X-Ray
CT
MRI
Ultrasound
EMG/NCS
Lab Work
Bone Scan
Other
Have you had any previous treatment for your current problem?
Physical/Occupational Therapy
Steroid Injections
Medications
Previous Surgery
Splints/Braces
Other
When was your most recent steroid injection?
Approximate or if known
Was the injection administered into the affected joint/area, or was it intramuscular (via the glute)?
Into Joint
Intramuscular (via glute)
Unknown/Other
Which medications have you tried for your current problem?
When and of what nature were any previous surgeries related to this problem?
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Pain Review
Please be as specific as you can about the pain you are experiencing. You may check as many boxes as you need.
Approximately how long have you been experiencing this problem?
*
1+ Year(s)
1+ Month(s)
1+ Week(s)
1+ Day(s)
How many years?
Exact or approximate range
How many months?
Exact or approximate range
How many weeks?
Exact or approximate range
How many days?
Exact or approximate range
How would you rate your pain?
*
Rows
0
1
2
3
4
5
6
7
8
9
10
0 = no pain,
10 = most pain
What is the severity of your symptoms?
*
None
Mild
Moderate
Severe
How often do you experience these symptoms?
Rarely
Occasionally
Frequently
Constantly
Since onset, have your symptoms been:
Worsening
Improving
No Change
When do you experience symptoms?
Morning
Daytime
Evening
Overnight
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Have you experienced any of the following?
*
Aching pains
Sharp pains
Shooting pains
Weakness
Stiffness
Locking
Grinding
Popping/Clicking
Instability
Numbness/tingling
Radiation down arm
Radiation down leg
Swelling
Bruising
Warmth
Redness
Drainage
Fever
Change in bowel/bladder habits
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What causes your symptoms to WORSEN?
*
Cannot Identify/None
Standing
Sitting
Sit to Stand
Laying Down
Sleep
Weight-bearing
Exercise
Walking
Running
Squatting
Lifting
Carrying
Pushing
Pulling
Twisting
Gripping
Squeezing
Throwing
Range of motion
Getting dressed
Writing/typing
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What causes your symptoms to IMPROVE?
*
Cannot Identify/None
Ice
Heat
Elevation
Rest
NSAIDs
Narcotics
Prescription medication
Over-the-counter medication
Braces/Splints
Sling
Limited weight-bearing
Stretching
Massage
Chiropractor
Physical/Occupational Therapy
Previous injections
Previous surgery
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Medical History
OPTIONAL: If preferred, upload a copy of your medication list and/or health/surgical history below:
Browse Files
Cancel
of
Are you currently taking any medications?
*
Yes
No
See submitted list
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
One medication per line, please!
Medication Name & Dosage (If known):
If additional spaces are still needed, please provide a copy of your medications to the front desk at your appointment.
Past Medical History:
*
No Significant Medical History
Anemia
Anxiety
Arthritis
Artificial Joint
Asthma
Bleeding Disorder
Blood Clots
Cancer
COVID-19
Depression
Type 1 Diabetes
Type 2 Diabetes
Gout
Heart Attack
Heart Disease
Heart Problems
Hepatitis Type A
Hepatitis Type B
Hepatitis Type C
Hernia
HIV
High Cholesterol
Hypertension (High Blood Pressure)
Kidney Disease
Liver Disease
Lung Disease (COPD)
Lung Disease (Other)
Migraines
Orthopedic Hardware
Osteopenia
Osteoporosis
Pacemaker
Pulmonary Embolism
Recurrent Infections
Rheumatoid Arthritis
Seizures
Seizure Disorder/Epilepsy
Stomach or Intestinal Problems
Stroke
Hyperthyroidism
Hypothyroidism
Tremors
Tumors
Ulcers
Other
Allergies:
No Known Drug Allergies
Adhesive Tape
Codeine
General Anesthesia
Iodine
IV Contrast
Latex
Lidocaine
Penicillin
Sulfa
Other
Have you had any previous surgeries?
*
Yes
No
See Attached List
Surgery Name
One per line, please! Please include right vs left if indicated.
Surgery Date
/
Month
/
Day
Year
Date if known
Surgery Name
One per line, please! Please include right vs left if indicated
Surgery Date
/
Month
/
Day
Year
Date if known
Surgery Name
One per line, please! Please include right vs left if indicated
Surgery Date
/
Month
/
Day
Year
Date if known
Surgery Name
One per line, please! Please include right vs left if indicated
Surgery Date
/
Month
/
Day
Year
Date if known
Surgery Name
One per line, please! Please include right vs left if indicated
Surgery Date
/
Month
/
Day
Year
Date if known
Surgery Name
If additional spaces are still needed, please provide a copy of your previous surgeries to the front desk at your appointment.
Surgery Date
/
Month
/
Day
Year
Date if known
Family Medical History:
Rows
Mother
Father
Sister
Brother
Arthritis
Diabetes
Heart Disease
Stroke
Cancer
Heart Attack
Hypertension
Deceased
No Family Medical History
Family Medical History Unknown
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Social History
Smoking Status:
*
Never Smoker
Current Smoker
Former Smoker
Chews Tobacco
Vape Only
If Current Smoker, how many per day?
LIGHT: 0-9 Cigarettes/Day
MODERATE: 10-19 Cigarettes/Day
HEAVY: 20-29 Cigarettes/Day
Other
Alcohol Use:
*
None
Socially
Occasional
Moderate
Heavy
Caffeine Use:
*
None
Occasional
Moderate
Heavy
History of Recreational Drug Use:
*
None
Marijuana
Other
Completed COVID-19 Vaccination Status:
*
Pfizer (both doses)
Moderna (both doses)
Johnson & Johnson
None
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