Patient Information

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

Medical History

 
Date:
Last name:
MI:
First name:
Date of birth:
Age:
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:

Symptoms

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:
Reaction?
Any latex allergy:
Reaction?

Social History

Hobbies:

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?
Per:
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

Anemia
Arthritis
Asthma
Blood clots / DVT
Cancer
COPD
Depression
Diabetes
Gout
Heart disease / CAD
Hepatitis
HIV
High Blood Pressure
High Cholesterol
Irregular heartbeat
Liver disease
Lung Disease
Metal allergy
Osteoporosis
Prostate
Psoriasis
Stomach ulcer / Reflux
Stroke
Seizures
Thyroid disease
Vascular disease
Other
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.

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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.