Patient Information

*Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.

Medical History

* Required Information
Last name:
First name:
Date of birth:
Email address:

Chief Complaint

*Reason for today's visit:
*Did the problem result from a specific injury?
Date of injury:
*Is this a work related injury?
*Has the injury been reported?
*Is this injury part of a lawsuit?
What is your occupation?
Please describe the onset of the problem (How did the problem start?):
*Dominant hand:


*What symptoms related to today's visit are you experiencing?
*Describe the symptoms (Quality):
*How long have you had symptoms? (Duration)
*How often do you have symptoms (Timing)?
*When do symptoms occur?
Pain Level (none=0, 10=severe):
*At worst:
*At best:
*What makes your symptoms worse?
*What makes your symptoms better?
*Are you on narcotic medication for this issue?
*Who is the prescribing physician?
*Have you had any prior injuries to the area?
*Have you had any previous treatment for this problem?
*Did any of these treatments provide relief?

Personal Medical History

*Are you pregnant?
*Please check previous or current medical conditions:
*Have you ever had or been treated for Hepatitis B?
Date cleared:
*Have you ever had or been treated for MRSA (Methicillin-resistant Staphylococcus Aurous)?
Date cleared:
*Have you ever had or been treated for Staph infection?
Date cleared:
*Do you have a history of Post-Operative infections?

Surgical History

Please list any surgeries you have had and the year:

Current Medications

*Medication allergies:
Name of the drug and reaction:
*Any metal allergies:
What metal?
*Any nickel allergy:
*Any latex allergy:

Social History


Tobacco Use
*Do you use nicotine products?
Date last used:
Date last used:
Date last used:
Date last used:
Date last used:
What is your smoking status?
At what age did you begin smoking?
At what age did you quit?
How many cigarettes per day?
How many cigars or pipes do you smoke per week?
How many cans of smokeless / chewing tobacco do you use per week?
Alcohol Use
*How often do you use alcohol?
*What type(s) of alcohol do you drink?
*How many drinks do you have per occasion?
*How often do you have more than five drinks per occasion?
*Drug Use

Family History

Blood clots / DVT
Heart disease / CAD
High blood pressure
High Cholesterol
Irregular heartbeat
Liver disease
Lung Disease
Metal allergy
Stomach ulcer / Reflux
Thyroid disease
Vascular disease
The information provided is true and complete, to the best of my knowledge and ability.  I understand that I am responsible for updating this information, if any of it changes, in a timely fashion.

IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 284
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.