SOCIAL HISTORY

Are you:
 
 
 
 
Are you pregnant or is it possible that you might be pregnant?
 
 
 
Marital Status:
 
 
 
 
 
Do you exercise?
 
 
 
 
 
 
 

TOBACCO

What is your smoking status?
 
 
 
 
 
Do you use any other tobacco or nicotine products? (e.g., the patch, nicotine gum, chewing tobacco, snuff, e-cigarettes, etc...)
 
 
 
 
 

ALCOHOL

Alcoholic drinks per day:
 
 
 
 
 
 
 

DRUGS

Please mark if applicable:
 
 
 
 

FAMILY MEDICAL HISTORY

Do you have any family medical history?

 
 
 
Please indicate which family members have had these illnesses:   Father Mother Brother Sister Son Daughter
Bleeding Tendency
Blood Clots
Cancer
Depression
Diabetes
Heart Attack
Heart Disease
High Blood Pressure
Osteoarthritis
Rheumatoid Arthritis
Stroke
Tuberculosis
 

ANESTHESIA HISTORY

Have you ever had an adverse reaction / problem with anesthesia?
 
 
Please explain:
 

YOUR MEDICAL HISTORY

Do YOU have any personal medical history?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Please specify type/s:  
 
 
Please list:  
 
 
Who:  
 
 
Please specifiy:  
 

SURGERIES

Have you had any surgeries?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Carpal Tunnel Surgery
 
 
 
 
Rotator Cuff Surgery
 
 
 
 
Arthroscopic Shoulder Surgery
 
 
 
 
Total Shoulder Surgery
 
 
 
 
Hip Fracture Surgery
 
 
 
 
Total Hip Surgery
 
 
 
 
Partial Hip Surgery
 
 
 
 
Total Knee Surgery
 
 
 
 
Partial Knee Surgery
 
 
 
 
Arthroscopic Knee Surgery
 
 
 
 
Foot Surgery
 
 
 
 
Achilles Tendon Repair
 
 
 

Spinal Fusion
 
 
 
Spinal Decompression
 
 

 
Please specify body part:  
 
 
Please specify:  

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 826
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.