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 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. have/had MI): pain? 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
