Medical History Information Sheet Template
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1
2Medical History Information Sheet
Patient Name:
Today's Date:
DOB:
Age:
Height:
Weight:
Visit Information
Reason for visit:
Referring Physician:
Primary Care Physician:
Type of pain:
Ache
Stabbing
Throbbing
Shooting
Dull
Click / Pop
Date of Injury:
___/___/___
Severity:
None 0 1 2 3 4 5 6 7 8 9 10 Intolerable
Duration of pain:
Location of pain:
Pain Aggravated By:
Treatments Attempted:
Standing
Walking
Lying
Pain Medications
Anti-Inflammatory
Rest
Sleeping
Working
Stairs
Wheelchair
Physical Therapy
Ice
Sitting
Driving
Surgery
NONE
Current Health
Please list any health problems that you are currently diagnosed with.
Seizures
Lung Disease
High Blood Pressure
Thyroid Problems
Pulmonary Embolism
Liver Disease
Heart Disease
Cancer
Stomach Ulcers
DVT (Blood Clots)
Osteoarthritis
Asthma
Diabetes
Kidney Disease
Rheumatoid Arthritis
Chronic Headache
Depression
Gout
High Cholesterol
Jaundice
Infections: Please explain:
Other Illness: Please explain:
Females Only:
Date of Last Menstrual Period:
___/___/___
Currently Pregnant?
Yes
No
Possibly
Surgical History
Please list any previous surgeries and approximate dates of surgery
Surgery:
Date:
Surgery:
Date:
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
___/___/___
NONE
Known Allergies to Anesthesia:
No
Yes
Describe:
Medications
Please list any medications that you currently use, including over-the-counter medications, vitamins, herbs, and prescribed drugs.
Medication:
Dose:
Medication:
Dose:
NONE
Allergies
Known Drug Allergies:
None Known
Iodine
Diagnostic Dyes
Morphine
Penicillin
Codeine
Aspirin
Ibuprofen
Sulfa Drugs
Acetaminophen
Latex
Metal
Other:
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Parent category: Medical