Patient Information

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

Personal / Family History

* Required Information

Current Problems Continued

*Are you working in spite of your injury/illness?
*Were you injured?
*Was this a work related accident?
*Was this an auto accident?
*How much pain are you experiencing now? (0 being no pain to 10 being most severe)
*Have you fallen in the past year?
*Are you pregnant?
*Which hand is dominant?

Your Medical History

*Do you have any medical history problems?
Please list cancer types:
Do you have a Cardiologist?
Chronic or Past Head / Neck Disorders:
Other medical history:

Family History

*Do you have any family medical history problems?
Bleeding Tendency
Blood Clots
Cancer
Diabetes
Heart Attack
Thyroid Disease
Osteoporosis
Stroke
Heart Disease
High Blood Pressure
Osteoarthritis
Inflammatory Arthritis

Social History

*What is your cigarette smoking status?
*Alcoholic drinks per day:
*Exercise times per week:
*Do you live alone?
*Do you have a living will?
*Have you had a pneumonia vaccine?
Year:
*Have you had a colorectal screening in the past 9 years?
Year:
*Have you had the flu vaccine / nasal mist?
Year:
*Are you currently being treated for osteoporosis?
*Have you had a bone density / DEXA scan?

Surgeries

*Do you have any surgeries?
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Date:
Fracture Repair of:
Date:
Hip Replacement
Date:
Knee Cartilage
Date:
Knee Ligament
Date:
Knee Replacement
Date:
Shoulder
Date:
Other surgeries:
*Have you ever had an adverse reaction / problem with anesthesia?
Please explain:
*Have you had blood relatives with anesthesia problems?
Please explain:

Review of Systems

*General
*Cardiovascular
*Endocrine
*Gastrointestinal
*Genitourinary
*Hematologic
*Skin
*Musculoskeletal
*Neurological
*Respiratory

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 450
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.