Elbow Patient History Form (Page 5 of 8) in pdf

Family History

Please check all diseases for which you have a family history:

Heart Disease

Cancer - Other

Stroke

Diabetes

Rheumatoid Arthritis

Problems with anesthesia

Arthritis - osteo, degenerative

Osteoporosis

Cancer - Breast

Reviewed and Unremarkable

Cancer - Prostate

Social H istory

Current Employment:

ull-time

art-time

etired

tudent

nemployed

isabled

Job Title: _______________________________________________________________________________________

Level of Education:

Grade school

High school/equivalent

Some college

College degree

Graduate degree

Alcohol:

Tobacco

I drink alcohol

I have never used tobacco

Rarely (less than 1 drink a month)

I currently smoke the following number

Occasionally (1-4 drinks per month)

of packs per day:

socially (1-2 drinks per week)

frequently (3-5 drinks per week)

2½

daily (at least one drink a day)

1½

I do not drink alcohol, but I used to drink

-Years of tobacco use at this pattern: ____ yrs

I never drank alcohol

I do not use tobacco, but I used to use

Exercise. Do you exercise regularly?

Yes

How often?

daily

3 times per week

weekly

at least once every other week

Allergies

A re you allergic to any medications?

Yes

No. Please list

_________________________________________________________________________________________________________________________

Current M edications

P lease list the medications you are currently taking - Please include prescription and non-prescription

medication. Please list doses and number of times taken daily

_________________________________________________________________________________________________________________________

Please check any anti-inflammatory medication listed below which you have taken in the past.

Please include all prescription, non-prescription and samples provided.

Advil

Lodine

Tylenol

Arthrotec

Naprelan

Ultram

Daypro

Naproxen

Other (specify)________

Ibuprofen

Celebrex

Please check any of the following side effects you experienced while taking any of the above anti-inflammatory

medications.

Nausea

Diarrhea

Gastric ulcers

Upset stomach

Vomiting

other______________________

Please check any of the following medications you take on a regular basis.

Aspirin

Axid

Coumadin

Cytotec

Heparin

Maalox

Mylanta

Prevacid

Pepcid

Zantac

Tagamet

Prilosec

Elbow Patient History Form Page 5

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