Name:

    Address:

    Phone Numbers:      Home:                         Work:                              Cell:

    Primary Care Provider (MD):

Address:

Phone:

    State your body part, problem and all symptoms:                Circle one:    Left    Right

    How long have you had this problem?

Prior injury to same area? Yes    No   

Date(s):  

    Date of Injury:                         Circle if applicable:         Work      Auto   Athletic Injury         

    Describe:

    Treatment to date?  Yes       No

 If yes: (circle all that apply)    Medications        Physical Therapy        Injections          Surgery

    Medical Problems (circle if applicable, describe):

      Blood Clots                            Heart Problems                           Lung Problems                        

      Cancer                                    Diabetes                                       Kidney Problems

      Stomach Ulcer                       Liver Problems                            Thyroid Problems

      Other medical problems (please list):

     Prior surgeries (please list):

     Anesthesia problems:      Yes          No              If yes, please explain:

     Please list all current medications:

      Allergies, please list and include specific reaction to each:

     Aspirin allergy:  Yes  No

Latex allergy: Yes    No    

Penicillin allergy:   Yes      No

     Family diseases, please list:

     Social History:        Job: ________________________Duties:

     Smoking: _______ Yes  ______Packs per day   _________No   (Quit: when:______)

     Alcohol ________________                          ________ drinks/day

     REVIEW OF SYSTEMS: 

     (CIRCLE ANY THAT APPLY, AND/OR ADD WHERE NECESSARY):

     Constitutional:     Weight Loss                  Weight Gain                    Fevers                             

                                   Night Sweats                        Fatigue                      Chills

      HEENT:       Eyes              Ears                 Sore Throat                  Ear Ringing

      Pulmonary:       Shortness of Breath     Asthma         Emphysema         Cough

                   Pneumonia       Tubercolosis       Positive PPD          Pulmonary Embolism

     Cardiac:            Heart Attack        Chest Pain             Heart Failure            Arrhythmia

                Fainting              High Blood pressure          Shortness of Breath on Exertion

      Gastrointestinal:         Ulcers           Abdominal Pain          Hepatitis              Jaundice

                     Rectal Bleeding           Dark Stools                Nausea                 Vomiting

                    Diarrhea                Constipation                  Abdominal Mass

      Urinary:        Infections       Bleeding       Kidney Stones       Frequency        Urgency

      Skin:           Psoriasis               Rashes                Itching              Skin Lesions

      Hematologic:     Leukemia/Lymphoma    Phlebitis    Bleeding/Bruising     Blood Clots

      Endocrine:      Excessive thirst      Weight Gain         Weight Loss        Goiter

            Changes in Hair       Changes in Skin          Cold Intolerance        Heat Intolerance

      Musculoskeletal:      Arthritis       Joint Swelling      Joint Pain      Neck Pain      Back Pain

         Fracture List:

         Joint Replacement: 

      Vascular:       Aneurysm          Leg Swelling               Phlebitis              Raynaud’s

      Immunologic:       Sensitivities/Allergies

      Other: