Orthopedic History
Patient Name
What are you seeing the doctor for today?
If this is a re-visit to our office for a new problem, list any changes to your health,
medicines, or allergies since previously seen.
Please describe how your injury happened.
Have you been treated by anyone else for this problem?
No
Yes
By whom, when and where were you treated?
Where you put on any medication for this problem?
No
Yes
If yes, what type of medication and are you taking it now?
What increases your pain or symptoms?
What decreases your pain or symptoms?
What is your current work status?
No Restriction
Working with Restriction
Off Duty
Disabled
Unemployed
Homemaker
Retired
If you are not working, what was your last day of work?
Please list previous hospitalizations and/or surgeries.
Medical History
Please check all that apply. If you have any questions about this form, or if there is other information which you have or which you feel might be
important, please discuss it with the doctor. Also, if any of the information that you hve provided should change, please inform the doctor. Thank you,
Community Orthopedic Surgery.
Chronic cough or lung problems
Shortness of breath at rest
Shortness of breath with exercise
Recent cold, bronchitis, or pneumonia
History of asthma or wheezing
High blood pressure
How many years?
Heart Attack
Date:
Heart Failure
Date:
Chest discomfort/tightness with exercise
Irregular heartbeat
Date:
Mitral valve prolapse
Heart murmur
Stroke/TIA/weakness/paralysis
Epilepsy/seizure
Date of Last Seizure:
Exam by cardiologist (heart doctor)
Heart catheterization
Exercise stress test
Ultrasound of heart (echocardiogram)
Pacemaker
Chronic back problems
Excess bleeding from surgery
History of anemia (low blood count)
Diabetes
Since:
Liver disease/jaundice/hepatitis
Kidney disorder
Stomach ulcer
Chronic heartburn
Hiatal hernia
Transfusion
Date:
Could you be pregnant
Date of last menstrual period:
Dentures/bridges/caps
Skin problems
Circulation problems
Hard of hearing
Wear glass/contact lenses
Problems walking
Chemotherapy
Immunizations up to date
History of motion sickness
Are you on a special diet
Problems chewing/swallowing
Depression/Psychiatric condition
Substance Abuse
Sleep Apnea
Drinks/Week:
Arthritis
Blood Clots
Cancer
Injury with long-term impairment
Joint pain
Numb arm or leg
Pulmonary embolism
Rheumatoid arthritis
Thyroid disease
Keloids
Lupus
Are you allergic to:
Check all that apply, and describe your reaction.
Latex
Reaction:
Any Food
Reaction:
Adhesive Tape
Reaction:
Iodine on your skin
Reaction:
Medication Allergies?
If you have any medication allergies, list them here and describe your reaction.
Medication:
Reaction:
Medication:
Reaction:
Medication:
Reaction:
Medication:
Reaction:
Medication:
Reaction:
Please list all prescription and non-prescription medications you are presently taking, including dosage and frequency.
Include non-prescription medications, such as iron, aspirin, antacid, laxatives, eyedrops, vitamins, and herbal supplements.
Medication:
Medication:
Medication: