Sheet1

Patient Name :________________________________________			Date: ______________________
Why are you being seen today? __________________________________________________________
_____________________________________________________________________________________________
Date problem/injury started: _______________Where did this happen? *Work * Auto* Home* Other
Age: ______ Occupation: ________________ Employer: __________________Are you working? _____
Referred By: ____________________ Family Physician: _____________________________________
Drug Allergies: _______________________________Allergic to:*Latex* Contrast * Adhesives*Seafood*
Current Medications: __________________________________________________________________
___________________________________________________________________________________
List any Surgeries: ____________________________________________________________________
CURRENT or PREVIOUS HEALTH CONCERNS:			Cardiovascular
Fever	Yes	No	Are you taking Coumadin?	Yes	No
Chills	Yes	No	Rheumatic Fever	Yes	No
Wgt Loss/Appetite Change	Yes	No	High Blood Pressure	Yes	No
Cancer	Yes	No	High Cholesterol	Yes	No
MRSA/VRE	Yes	No	Pacemaker/Metal Parts	Yes	No
Pregnant	Yes	No	Irregular Heart Beat/Palpitations	Yes	No
Psychological			Chest Pain	Yes	No
Depression	Yes	No	Heart Disease	Yes	No
Anxiety	Yes	No	Heart Attack: Date______________
Assistive Devices			Bladder/Kidney
Cane/Walker/Wheelchair	Yes	No	Kidney Failure	Yes	No
ENT/Mouth			Pain with Urination	Yes	No
Deafness	Yes	No	Incontinence	Yes	No
Sinusitis	Yes	No	Hesitancy	Yes	No
Hoarseness	Yes	No	Gastrointestinal
Ringing in Ears	Yes	No	Liver Disease/Cirrhosis/Hepatitis	Yes	No
Respiratory			Heartburn	Yes	No
Asthma	Yes	No	Ulcers	Yes	No
Wheezing	Yes	No	Diarrhea	Yes	No
Shortness of Breath	Yes	No	Constipation	Yes	No
Sleep Apnea	Yes	No	Abdominal Pain	Yes	No
Cough	Yes	No	Allergic/Immunologic	Yes	No
Cough up Blood	Yes	No	Rhematoid Arthritis/Lupus	Yes	No
Skin			Reaction to Anesthesia	Yes	No
Eczema	Yes	No	Other Medical Problem	Yes	No
Rash	Yes	No	Endocrine
Lesion	Yes	No	Diabetes (Age of onset?) _______	Yes	No
Ulcer	Yes	No	Thyroid Problems	Yes	No
Scar	Yes	No	Growth Problems	Yes	No
Neurological			Blood Disorders
Stroke	Yes	No	Anemia/ Sickle Cell	Yes	No
Numbness	Yes	No	Bleeding or bruising easy	Yes	No
Tingling	Yes	No	Varicose Veins	Yes	No
Seizures	Yes	No	Blood Clots	Yes	No
Problems with Speech	Yes	No	Lymph node Pain/Enlargement	Yes	No
Stroke	Yes	No	HIV Positive	Yes	No
Balance/Dizziness	Yes	No	Social History
Weakness	Yes	No	Do you Smoke?	Yes	No
Memory Problems	Yes	No	Packs per Day________
Migraine	Yes	No	# of Years __________
Eyes			Do you average 3 or more
Double Vision	Yes	No	alcoholic drinks per day? ______	Yes	No
Blurry Vision	Yes	No	Do you use recreational drugs?	Yes	No
Glaucoma	Yes	No	Do you live alone?	Yes	No
Glasses	Yes	No	Do you have Children?	Yes	No
Cataracts	Yes	No	Do you reside in a nursing facility?	Yes	No
COMMENTS: _______________________________________________________________________________________
Family History:	Living?		Has any blood relative had the following?
Mother	yes/no		Epilepsy Glaucoma Diabetes Asthma
			Hypertension High Cholesterol Alcoholism
Father	yes/no		Thyroid Heart Disease Cancer Migraines
			Arthritis
Brother How Many?______	yes/no		Which family member experienced these conditions?
Sister ______	yes/no		__________________________________________________