NAME OF PATIENT
*
First Name
Last Name
D.O.B
*
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Day
Please select a month
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Month
Please select a year
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1920
Year
FAMILY DOCTOR
*
OCCUPATION
*
CELL TEL
*
WORK TEL
ADDRESS
*
EMAIL
*
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PRESENT HISTORY
Check/Circle Involved Body Part(s)
*
Hand
Wrist
Elbow
Shoulder
Neck
Back
Hip
Knee
Ankle
Foot
None
Kidney Problems
Check Involved Side(s):
*
Right
Left
Both
None
What is your main complaint?
*
Date of accident or onset of symptoms
*
Allergies:
*
What medications have you used for this problem?
*
Have you seen a doctor for this condition?
*
Yes
No
Name
Have you been diagnosed with a specific problem for this condition?
*
Yes
No
Other (Please describe):
What tests/treatments have you had?
*
X-rays
CT scan
MRI
Bone Scan
Injections
Stem Cells
None
Other
PAST MEDICAL HISTORY (“I have had or have the following problem(s)”, Please select any and all that apply)
*
Diabetes
Gout
Bleeding
Disorders
Thyroid
Heart Disease
Phlebitis
Ulcers
Asthma
High Blood Pressure
Hepatitis
Kidney Problems
HIV
Arthritis
Seizures
Sickle Cell Disease
Stroke
Osteoporosis
Lung Disease
Tuberculosis
Rheumatoid Arthritis
Mental Illness
Other
None
Cancer (List Type)
If selected option "Other" then please provide details.
LIST ALL ALLERGIES TO MEDICINES AND FOODS AND REACTION: (If none write NKDA)
*
LIST ALL CURRENT MEDICATIONS WITH THEIR DOSAGE:
Medication
Dosage
Medication
Dosage
1
2
3
4
5
6
7
LIST ANY PRIOR SURGERY (Include Dates):
*
FAMILY MEDICAL PROBLEMS: (Please select any and all that apply)
*
Diabetes
Gout
Bleeding Disorders
Thyroid
Heart Disease
Phlebitis
Ulcers
Asthma
High Blood Pressure
Hepatitis
Kidney Problems
HIV
Arthritis
Seizures
Sickle Cell Disease
Stroke
Osteoporosis
Lung Disease
Tuberculosis
Rheumatoid Arthritis
Mental Illness
None
Cancer (List Type):
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SOCIAL HISTORY
Do you smoke?
*
Yes
No
Did you smoke in the past?
*
Yes
No
When did you quit?
Do you drink alcohol?
*
Yes
No
How often do you drink:
Do you use illicit drugs?
*
Yes
No
When do you use illicit drugs?
Daily
Weekly
Monthly
Height:
*
Weight:
*
REVIEW OF Symptoms ("I have these symptoms related to my problem", please select all that apply)
*
Fevers
Chills
Sweat
Weight Loss
Bruising
Rash
Hives
Bleeds
Leg Swelling
Headaches
Ringing in ears
Balance Problems
Palpitations
Nausea
Vomiting
Painful Urination
Constipation
Abdominal Pain
Impotence
Goiter
Cold Intolerant
Fainting
Paralyses
Weakness
Dizzy
Numbness
Tremor
Joint Pain
Sleeping Difficulties
Back Pain
Neck Pain
Joint Swelling
Muscle Cramps
Stiffness
High Blood Pressure
None
Other
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Insurance Information
Insurance Company
Insurance Number
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EMERGENCY CONTACT
Name
*
Tel
*
Please enter a valid phone number.
Patient Signature
*
Date:
Submit
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