• Medical Questionnaire - Adult

  • May we send your physician(s) a report of this visit?

  • Your Current Problem

  • When did this problem begin (date of injury)?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this a work related problem?
  • Is there an attorney involved with your case?

  • Social History

  • What is your work status?
  • What level of activity is required in your workplace
  • Marital Status
  • Do you use tobacco?
  • What type?
  • Did you previously use tobacco?
  • Do you use alcohol?

  • If yes, # of drinks Daily Weekly      Monthly

  • Do you use any street drugs?
  • Do you have any history of drug or alcohol abuse?
  • Do you follow a special diet?

  • Past Medical History

  • Please check boxes of any past medical problems that you have had

  • Past Surgical History

  • Please list all of the operations that you have had in your lifetime.

  • Medications Acute/Current List

  • Please list all medications including over the counter medicines, herbals and prescription medications that you take.
    Rows

  • Allergies

  • Please list all medications and substances that you are allergic to.

  • Medication allergy
    Rows

  • Family History

  • Please check illnesses that have occurred in any of your blood relatives.
  • Relation
    Rows

  • Review of  Systems/Current Symptoms

  • Are you currently having or have you recently had any of the following problems?

  • Constitutional
    Rows
  • Ears, Nose, Throat
    Rows
  • Cardiovascular
    Rows
  • Respiratory
    Rows
  • Gastrointestinal
    Rows
  • Musculoskeletal
    Rows
  • Eyes
    Rows
  • Skin
    Rows
  • Neurologic
    Rows
  • Endocrine
    Rows
  • Cancer
  • Genitourinary
    Rows
  • Mental Health
    Rows
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Time
  • Should be Empty: