Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.PATIENT NAME (LAST, FIRST, MI):LAST NAME *FIRST NAME *MIDDLE INITIALReason For Appointment * PRESCRIPTION MEDICATIONS MedicationMedicationMedicationMedicationMedicationMedicationMedicationMedication If Modifying Signs/Symptoms PREVIOUS SURGERIES TYPE:YEAR:TYPE:YEAR:TYPE:YEAR:TYPE:YEAR:TYPE:YEAR:TYPE:YEAR:TYPE:YEAR:TYPE:YEAR:ALLERGIES TO MEDICATIONS List all allergies to medication Medications Allergic To:Please list all allergies to medicationsAllergic Reaction:Please describe allergic reaction: ie; hives, rash, itching, swelling, feverDo you have low back pain?YesNoNAHistory of drug abuse?NoYesNADo you drink alcohol?YesNoIf Yes, what amount?Do you smoke?YesNoIf yes, what amount? Please indicate if you have quit.Are you currently pregnant?NoYesNumber of monthsMEDICAL PROBLEMS: Please check if you have/had the following: Select ALL that apply.NeuropathyFibromyalgiaAsthmaKidney DiseaseHepatitis AHepatitis BHepatitis CThyroid ProblemsLiver TroubleAids/HIVDiabetesGoutVaricose VeinsCOPDAnemiaStrokeBleeding DisorderBlood ClotsStomach ProblemsHigh Blood PressureHeart ProblemsArthritis RheumatoidArthritis OsteoporosisHigh CholesterolDescribe Other Medical Conditions: For Stomach and Heart problems, please discribe.FAMILY MEDICAL HISTORY: (Select all that apply) - FAMILY MEMBERS WITH HYPERTENSIONMotherFatherGrandparentSiblingFOOT PROBLEMS - Family MembersMotherFatherGrandparentSiblingDIABETES - Family MembersMotherFatherGrandparentSiblingHeight *Weight *Shoe Size *CONFIRMATION Medical History Terms & Conditions *I agree with the terms and conditions required of the family medical history form.1. YOUR AGREEMENT I understand that honest and complete answers to each question stated above are important to the provision of my medical care, and I have answered them to the best of my ability. I have been informed that if I am uncertain about any questions on the form, I should ask the doctor or member of the medical staff for assistance. This information is true and accurate to my knowledge. DATE: *MM/DD/YYYYPATIENT SIGNATURE *CURRENT MEDICAL HISTORY Please assist us by letting us know the reason you are here to see us today: Location:Where is the pain or problem?Quality:Example: Does it ache, burn, etc? Pain after Rest or after activity, etc.?Severity:How severe is the pain or problem on a scale of 1-5 with 5 being the most severe?Duration:How long have you had this pain or problem? When did it start?Timing:Does the pain or problem occur at a specific time?Context:Where were you at the onset of the pain or problem?Associated Signs/SymptomsWhat other associated problems have you been having?Modifying factors:What makes the pain or problem worse or better? Have you had previous episodes?Submit
