Medical History
Today's Date
-
Month
-
Day
Year
Date
Patient's Name
First Name
Last Name
General Information
Is this injury related to?
Work
Car Accident
Other Liability/Potential Lawsuit
Not Applicable
Do you have a Primary Care Physician / Family Doctor?
Yes
No
Have you had an appointment with him / her in the last 12 months?
Yes
No
Race/Ethnicity (Please selectone):
Hispanic or Latino Origin
(includes Mexican, Cuban, Puerto Rican,
and other Latin American and Spanish)
Not Hispanic
Asian or Pacific Islander
African American
Native American, Eskimo, or Aleutian
Caucasian (White)
Other
Declined
If you are a Medicare beneficiary, you are required by Medicare to answer the following question:
Do you consume more than 7 alcoholic drinks in a week?
Yes
No
Please Mark One Box For Each Item
No
Yes Under
a year
Yes Over
a year
No Answer
/Invalid
Smoking
Sexual dysfunction
Diabetes
Bladder / bowel problems
Heart condition
Groin numbness
High blood pressure
Arthritis
Chest pain
Osteoporosis
Stroke
Psychological condition
Kidney condition
Seizures
Blood clot / DVT
Dizziness / faintness
Metal implants / pacemaker
Ringing in ears
Breathing difficulties / asthma
Allergy to latex (gloves)
Cancer
Other allergy
Difficulty swallowing
Head Injury
Circulation/vascular problems
Obesity
Peripheral neuropathy
Chronic pain/fibro/headaches
Unexplained weight loss
Fractures
Double vision
Infection
Night sweats / night pain
Fever / nausea
Are you pregnant?
Infection Disease
Yes
No
If yes, please specify the condition
Neurologic Condition (MS/Parkinson’s)
Yes
No
If yes, please specify the condition
Pediatric Developmental Condition
Yes
No
If yes, please specify the condition
Skin Disease
Yes
No
If yes, please specify the condition
Spinal Cord Injury
Yes
No
If yes, please specify the condition
Degenerative Joint Disease
Yes
No
Type a question
Spine
Upper Extremity
Lower Extremity
Medication
Dosage
Frequency
Route of Administration
1
2
3
4
5
6
7
8
9
10
Submit
Should be Empty: