Unm Orthopaedics Health History Family Health History Template
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1UNM Orthopaedics Health History
Form
***This form will become part of your medical record. Please
fill out as accurately as possible.***
Patient Name:______________________________________
Date of Birth:______________
Age:_______
Are you RIGHT or LEFT handed?
Name of REFERRING medical provider:____________________________________________
(MD, DO, PA, RNP, chiropractor)
Do you have, or have you
List details to these or any
List any SURGERIES you have had and, if known,
ever had, any of the
OTHER Medical Problems you
the YEAR and the name of the Surgeon:
following MEDICAL
Circle your
have or have had:
PROBLEMS:
answer:
Heart attack
YES NO
High blood pressure
YES NO
High cholesterol
YES NO
Diabetes
YES NO
Stroke
YES NO
Asthma
YES NO
Emphysema/COPD
YES NO
Ulcers/Reflux
YES NO
Rheumatoid arthritis
YES NO
Gout
YES NO
Seizures/Epilepsy
YES NO
Thyroid disease
YES NO
Hepatitis
YES NO
HIV/AIDS
YES NO
Cancer
YES NO
FAMILY HISTORY
Do any of your grandparents, parents or siblings have
List any DRUG ALLERGIES:
any of the following:
Diabetes
YES
NO
High blood pressure
YES
NO
Circle any of the following if you are ALLERGIC:
Heart attack
YES
NO
Iodine
IV Contrast
Shellfish
Latex
Stroke
YES
NO
List any MEDICATIONS you are taking:
Rheumatoid arthritis
YES
NO
Bleeding disorders
YES
NO
Cancer
YES
NO
REVIEW OF SYSTEMS:
Do you have NOW, or have you had
RECENTLY, problems with any of
Circle your
the following:
answer:
Fevers, chills, weight loss
YES NO
Eyes
YES NO
Ears, Nose, Throat
YES NO
Teeth, Mouth
YES NO
Chest pain, Heart Problems
YES NO
Shortness of Breath, Lungs
YES NO
Constipation, Diarrhea
YES NO
Urinary tract infection
YES NO
SOCIAL HISTORY:
Joint pain, Joint stiffness
YES NO
Are you employed? YES NO
Skin rashes, lesions
YES NO
Occupation___________________________________ Date last worked:______________
Migraines, Headaches
YES NO
Do or did you ever smoke? YES NO
_____Packs per day for_______ years
Blackouts/Falling
YES NO
Did you quit?
YES NO
If so, when did you quit?______________________
Balance problems
YES NO
Other tobacco/nicotine products? YES NO
What kind? ___________________
Psychological problems/Depression
YES NO
High cholesterol
YES NO
Drink alcohol? YES NO
How much and how often?_____________________
Diabetes
YES NO
History of illegal drugs/substance abuse? YES NO
Bleeding disorders
YES NO
What kind?______________________________________
Blood clots, DVT
YES NO
Seasonal allergies
YES NO
Are you: Single Married
Divorced
Separated
Widowed
Do you live alone? YES NO
Do you Exercise? Never
Rarely
Weekly
Daily
What type?________________________________________
Patient Label
Patient Signature: ____________________________________________ Date: _____________
MD Signature: _________________________________________________ Date: _____________
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