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Microsoft word - hedley-tempephoneix-medicalhistory.docx

DATE:__________________
PATIENT MEDICAL HISTORY FORM
HEIGHT: WEIGHT:
CHIEF COMPLAINT:
WHY are you here today?

WHICH
side is involved: ___Right ___Left ___Both
HOW did the INJURY or PROBLEM Happen? ___Accident ___ Auto Accident ____Work Accident __Other
WHEN did the INJURY or PROBLEM Begin?
SURGICAL HISTORY:
Have you ever had a general anesthesia? ___Yes ___No
Have you ever had any problems with anesthesia? ___Yes ___No / Explain Reaction:
List ALL of the surgeries that you have had:

ALLERGIES:
Please Circle the medications below that you are allergic to:
Latex Aspirin Codeine Sulfa Penicillin Keflex Betadine Tape
List any other Medication Allergies:


SOCIAL HISTORY
Work status: ___Full time ___Part time ___Work at home ___Retired ___Disabled ___Student Marital Status: ___Married ___Separated ___Single ___Live with Spouse or Other ___Live Alone Recreational Drug Use: ___Yes ___No / What kind of drug:
Alcohol use: ___Yes ___No / ___Daily ___1-2 drinks per week ___More than 2 drinks per week
Tobacco Use: ___Yes ___No / Packs per day:
PATIENT MEDICAL HISTORY continued
Patient Name:
FAMILY HISTORY
Mother ___Alive ___Deceased / cause of death: Brother ___Alive ___Deceased / cause of death: MEDICATIONS INCLUDING ALL VITAMINS, MINERALS AND HERBS:
REVIEW OF SYSTEMS
Please Circle all of the following Medical Problems or Conditions that you have, or have had:
Constitutional: unexplained weight loss/gain, fever chills, fatigue
Eyes: corrective lenses, blurred/double vision, eye pain
ENT: Headache, difficulty swallowing, nose bleeds, ringing in ears, earaches
Cardiovascular: Chest pain, palpitations, fainting, mummers, High Blood Pressure, Pacemaker
Respiratory: Short of breath, wheezing, cough, tightness, snoring, inspiration pain
Gastrointestinal: Heartburn, nausea, vomiting, constipation, diarrhea, bloody/tarry stools
Genitourinary: Frequency, urgency, difficult / painful urination, Flank pain, bleeding
Musculoskeletal: Joint Pain, Swelling, instability, stiffness, redness, muscle pain
Skin: Skin changes, poor healing, rash, itch, redness
Neurologic: Numbness/ tingling, unsteady gait, dizziness, tremors, seizures
Psychiatric: Nervousness, anxiety, depression, hallucinations
Hematologic: easy bleeding, easy bruising
Endocrine: excessive thirst or urination, heat or cold intolerance, Diabetes
Allergic: Reaction to foods or environment
Sleep Apnea / Use C-pap Machine
Hepatitis
HIV / AIDS
Other Medical Problems:

Patient Signature___________________________________ Form Reviewed ______________________M.D.
Page 2

Source: http://www.hedleyortho.com/wp-content/uploads/2013/10/Hedley-TempePhoneix-MedicalHistory.pdf

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