Académique Documents
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Name: _________________________________________
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Mild
Moderate
Severe
TENS unit
Narcotic medications
Cass/boot
Massage/Ultrasound
Traction
Anti-Inflammatories
Orthotics
Manipulation
Surgery
Steroid injections
Braces
or left ___?
Specialty
City
Treatment
ORTHOPEDIC HISTORY
Dose
Reason
Date
Location
X-Rays
MRI
CT Scan
Bone Scan
Other
Because of this problem, have you filed or do you plan to file a lawsuit? Yes
No
If you are a new patient to our practice, please complete the Comprehensive Health History. If you
have previously completed a Comprehensive Health History during a visit to our practice, have there
been any changes to your medical history, surgical history or medications since that time? Please
describe any changes below:
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Responsible partys signature :____________________________________
______________________________________
______________________________________
______________________________________
______________________________________
None Apply
Heart attack
Asthma
Rheumatoid arthritis
Depression
Heart failure
Tuberculosis
Osteoarthritis
ADHD
Abnormal heartbeat
Emphysema
Gout
Seizures
Thyroid
Osteoporosis
Migraine
Stroke
Stomach ulcers
Cirrhosis
Cerebral palsy
Gastric reflux
Hepatitis (A, B or C)
Downs syndrome
Hiatal hernia
HIV/AIDS
Spina bifida
Poor circulation
Kidney failure
Bleeding disorder
Neurofibromatosis
High cholesterol
Kidney stones
Anemia
Neuropathy:
Hands or
Feet
Cancer: _________________________________________________________(type/treatment)
Diabetes: year diagnosed __________
Currently controlled with
insulin
oral medications
diet
Other: __________________________________________________________________________
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PAST SURGICAL HISTORY:
Operation
No Prior Surgery
Date
Surgeon/Hospital
Dose
ALLERGIES TO MEDICATIONS:
No Allergies
Name of Medication
I take no medications
Reason
METAL ALLERGIES:
No Allergies
YES_______________________________(List Metals)
SOCIAL HISTORY:
Work status
Working
Homemaker
Unemployed
Disables
On Leave
Retired
Student
Occupation_________________________________________________________________________
Marital Status:
Children
No
Single
Married
Divorced
Widowed
Do you live alone? ______ If no, who lives with you? ______________________________________
Are you currently smoking?_____ If yes, how many packs a day?___ For how many years?_______
How many packs a day did you previously smoke? ___ Other forms of tobacco? ________________
Never
Rare
Social
Frequently (more than twice a week)
Alcoholic
Recovering Alcoholic
Never
In the past
Currently Types of Drugs_____________________
Illegal Drug Use
Alcohol Use
None Apply
Heart problems
Diabetes
Arthritis
Bleeding problems
Seizure
Cancer
Stroke
Gout
Kidney problems
Lung problems
Mental Illness
Alcoholism
Other: _____________________________________________________________________________
REVIEW OF SYSTEMS: (In the past 30 days have you experienced any of the following?)
Fever
Nausea
Chills
Hoarseness
Vomiting
Weight loss
Cough
Diarrhea
Vision changes
Trouble swallowing
Constipation
Vision changes
Chest pain
Hemorrhoids
Glasses/Contacts
Palpitations
Stomach pain
Hearing loss
Swollen ankles
Urinary difficulty
Dizziness
Shortness of breath
Anxiety
Ear pain
Seasonal allergies
Hyperactivity
Nosebleeds
Skin rashes
Memory loss
Toothache
Swollen glands
Blackouts
Gum problems
Poor appetite
Headache
I have not experienced any of the above symptoms in the last 30 days
Other: __________________________________________________________________________
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