New Patient Ortho Med History

Fields with a red asterisks are required fields and must be completed to proceed. If you are unable to complete online, we will ask you to complete the forms at the time of your appointment.

PATIENT INFORMATION

First Name *

Last Name *

Middle Name

Age

Date of Birth *

Sex

Height

Weight

lbs

Handed

Right

Left

Occupation

REFERRING PHYSICIAN

Name

Street

Suite

City

State

Zip Code

Phone

Working now?

Yes

Disabled

Retired

If retired, what was your previous occupation

PREFERRED PHARMACY

Pharmacy

Address

Phone

PRIMARY CARE PHYSICIAN (if different than above)

Name

Address

Phone

HISTORY OF PRESENT ILLNESS

REVIEW of SYSTEMS

Have you ever experienced or do you currently have any of the following signs or symptoms? If "Yes", please describe:

SYMPTOMS *	Yes	No	Describe all "Yes" responses
Eyes (e.g. blurred vision, double vision, loss of vision)
Ears, Nose, Throat (e.g. sore throat, earache, ringing)
Cardiovascular (e.g. chest pain, palpitations, ankle swelling)
Respiratory (e.g. shortness of breath, cough, snore)
Gastrointestinal (e.g. ulcer, gastritis, GI bleed, jaundice)
Genitourinary (e.g. burning, bleeding or difficulty urinating)
Musculoskeletal (e.g. joint, muscle, back or neck pain)
Skin (e.g. delayed healing, rash, acne, cellulitis, psoriasis )
Neurological (e.g. numbness, tingling, weakness)
Mental Health (e.g. depression, anxiety, memory loss)
Endocrine (e.g. weight gain/loss, excess thirst or urination)
Hematologic (e.g. bruising, bleeding or clotting disorder)
Allergic / Immunologic (e.g. rash, swelling, wheezing)

PAST MEDICAL and FAMILY HISTORY

Have you or a family member had problems with any of the following? Please indicate "Yes" with an “x”.

DISEASE/CONDITION	Self	Father	Mother	Sibling	Child	Grand Parent
Abnormal Heart Rhythm
AIDS
Anemia
Angina
Arthritis
Asthma
Bleeding Disorder
BPH (bengnprostatic hyperplasia)
Cancer
Cardiomyopathy
Cloting Disorder
Colitis
COPD
Diabetes Mellitus
Eozema
Emphysema
Endocrine Problem
Gall Bladder Disease
GERD
Heart Valve Problem

DISEASE/CONDITION	Self	Father	Mother	Sibling	Child	Grand Parent
Hepatitis
High Blood Pressure
High Cholesterol
HIV
Kidney Failure
Kidney Stones
Liver Problem
Mental Disorder
MI (myoocardialinfation)
Osteoporosis
Psoriasis
Psychiatric Problem
Seizures
Sickle Cell Anemia
Stroke
Thyroid
TIA (transientischemic attack)
Tuberculosis
Ulcer
Urinary Tract Infection
Other

PAST SURGICAL HISTORY: *

Procedure

Surgeon

Date

Procedure

Surgeon

Date

Procedure

Surgeon

Date

SURGICAL COMPLICATIONS *

ANESTHESIA: Have you ever had problems with anesthesia? *

Yes

If yes, please describe

BLOOD: Have you ever had a blood transfusion?

Yes

Do you have a history of blood clotting?

Yes

SLEEP APNEA:

Do you have Sleep Apnea?

Yes

Snore?

Yes

Stop breathing during sleep?

Yes

Medication	Dosage	Frequency	Route of Administration
MEDICATIONS (Prescription / Nonprescription / Herbal supplements / Vitamins / Other):

ALLERGIES: Please list type of allergy (medications, latex, food, metals, etc.) and type of reaction you experience:

SOCIAL HISTORY:

Student

Yes

School Grade Sport

Tobacco use:

Current every day smoker

Current some day smoker

Year started smoking

Tobacco use:

Heavy tobacco smoker

Light tobacco smoker

Tobacco use:

Never smoker

Former smoker

Year Quit

Alcohol use:

Never

Occasional

Daily

Heavy

History of alcoholism?

Yes

History of drug use?

Yes

Marital status:

Do you live alone?

Yes

If no, who do you live with?

Are you residing in a skilled nursing facility (SNF) either temporarily or permanently?

Yes

Are you pregnant?

Yes

Breastfeeding?

Yes

Date of last menstrual period

Comments or Clarification:

Patient/Guardian Statement:

I agree that my electronic signature will have the same effect as an original handwritten signature.

I have read this Electronic Record and Signature Disclosure.

To the best of my knowledge, the above information is accurate and complete.

Choose alternative style

Guardian Signature:

I agree that my electronic signature will have the same effect as an original handwritten signature.

I have read this Electronic Record and Signature Disclosure.

To the best of my knowledge, the above information is accurate and complete.

Choose alternative style

Date

Guardian/Authorized Representative Printed Name