Patient Health History Form

* Required

Personal Information






No significant medical history

Mother
Father
Brother
Sister


Mother
Father
Brother
Sister


Mother
Father
Brother
Sister


Mother
Father
Brother
Sister


Mother
Father
Brother
Sister

Mother
Father
Brother
Sister


Mother
Father
Brother
Sister


Mother
Father
Brother
Sister


Mother
Father
Brother
Sister

Mother
Father
Brother
Sister


Mother
Father
Brother
Sister


Mother
Father
Brother
Sister


Mother
Father
Brother
Sister
I take NO medications







I have no medical allergies


Tape
Metal
Latex
Eggs
None of these

Currently use
Previously used
Do not/have not used








Currently use
Previously used
Do not/have not used






Currently use
Previously used
Do not/have not used






Currently use
Previously used
Do not/have not used






Blood thinners
Diabetes
Jehovah's Witness
Kidney disease
Liver disease
Previous MRSA
Rheummatoid arthritis
Peptic ulcers
Past phlebitisembolismor DVT
Sleep apnea
Pacemaker
Claustrophobic
Pregnant
None of the above



None of these apply
AIDS/HIV
Alcoholism
Alzheimers
Anemia
Angina
Arthritis
Asthma
Atrial fib
Cancer
Stroke
Heart failure
COPD/emphysema
Cardiac artery disease
Crohn's disease
Degenerative joints
Depression
Fibromyalgia
Gallbladder disease

None of these apply
Hiatal hernia/reflux
Gout
Hepatitis
Hyperlipidemia
High blood pressure
Inflammatory bowel/Chron's
Juvenile rheumatoid arthritis
Kidney failure
Lyme disease
Multiple sclerosis
Heart attack
Osteoarthritis
Osteoporosis
Parkinson's
Psoriasis
Peripheral vascular disease
Rheumatoid arthritis

None of these apply
Scoliosis
Seizures
Lupus
Spinal stenosis
Thyroid disease
Heart valve disease
Other



None of these apply
ACL surgery
Angioplasty
Angioplasty and stent
Arthroscopy ankle
Arthroscopy elbow
Arthroscopy hip
Arthroscopy knee
Arthroscopy wrist
Arthroscopy shoulder
Back surgery
CABG/heart bypass
Heart valve replaced

None of these apply
Carpal tunnel release
Gallbladder removal
Colon removal
Colostomy
Disc surgery
Gastric bypass
Hernia repair
Hip arthroscopy
Hip replacement
Knee replacement
Laminectomy

None of these apply
Meniscus surgery
Muscle biopsy
Fracture surgery
Rotator cuff repair
Bowel resection
Thyroidectomy
Tonsillectomy
Hysterectomy
Mastectomy
Lumbar fusion
Cervical fusion
Other



None of these apply
Chills
Fever
Night sweats
Weakness
Weight loss
Blurred vision
Headache
Hearing loss
Ringing in ears
Vertigo
Vision loss
Chest pain
Cough
Shortness of breath
Recent infections
Known TB exposure
Heart murmur
Leg swelling

None of these apply
Syncope or fainting
Irregular heartbeat
Abdominal pain
Constipation
Black tarry stools
Diarrhea
Loss of appetite
Nausea
Vomiting
Painful urination
Frequent urination
Bloody urine
Urinary incontinence
Cold intolerant
Heat intolerant
Difficulty walking
Dizziness
Poor coordination

None of these apply
Memory loss
Muscle weakness
Seizures
Depression
Insomnia
Contact allergy
Itchy skin
Rash
Skin infections
Skin lesion
Bleeding
Brusing
Asthma
Other