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PATIENT MEDICAL HISTORY

Patient First Name

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Middle Name

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Patient Last Name

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Email

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Date of Birth

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Current Height

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Current Weight

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Occupation:

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Primary reason for appointment(list single problem here)

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How long have you had this problem?

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Have you received treatment?

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Have you had any of the following and if yes please document date had procedure(s):

X-Ray:

Yes

No

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Date:

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MRI:*

Yes

No

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Injection:

Yes

No

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Prior surgery:

Yes

No

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Physical Therapy:

Yes

No

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(If yes to any of imaging/injections/surgery, please have records sent before appointment) Please list all current medications and dosage: (Attach List if needed)

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Are you on any blood thinners?

Yes

No

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Please list any allergies

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Are you allergic to Latex?

Yes

No

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PAST SURGICAL HISTORY (Please list all orthopedic surgeries, surgeon performed by and date”

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Please List All Other Surgical History:

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SOCIAL HISTORY:

SOCIAL HISTORY:

Alcohol Consumption?

Yes

No

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Frequency:

Daily

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Social

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Quantity

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Occasionally

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Tobacco Use?

Yes

No

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If Yes,

Daily

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Occasionally

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Do you live in a smoke-free home?

Yes

No

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FAMILY HISTORY OF DISEASES

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Please check that apply and list diagnosis:

Blood Disorders

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Eye, Ear, Nose, Throat Disease

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Heart Disease

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Kidney Disease

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Other Medical Problems not listed above

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Liver Disease

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Lung Disease

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Skin Disease

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Stomach or Colon Disease

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Review of Systems

Review of Systems

Please check all that apply:

General

Fatigue

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Decreased appetite

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Fevers

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Weight Loss

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Weight Gain

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Insomnia

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Ear Nose and Throat

Visual Changes

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Hearing Loss

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Sore Throat

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Nasal Congestion

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Runny Nose

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Ear Pain

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Lymph

Swollen glands in neck, armpits, or groin

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Respiratory

Shortness of Breath

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Cough

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Wheeze

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Cardiovascular

Chest Pain

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Palpitations

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High blood pressure

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Stroke

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Syncope

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Edema(Swelling of legs)

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Gastrointestinal

Abdominal pain

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Constipation

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Bloody stool

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Diarrhea

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Heartburn

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Nausea/Vomiting

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Bloody/Black Stool

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Genitourinary

Change in bowel habits

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Painful urination

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Bloody urine

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Increased frequency

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Gynecologic

Irregular menses

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Abnormal discharge

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Pelvic pain

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Skin

Rash

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Itching

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Ulcers

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Neurologic

Headaches

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Dizziness

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Numbness or tingling

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Loss of consciousness

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Other:

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I, certify that this information is to the best of my knowledge and believe is true, correct and complete.

I give, CCSRM/Ahmed Khan, M.D., permission to release medical information to the above referring physician.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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