LONE STAR ORTHOPEDICS, P.A.                                                                                            Back to welcome

NOTE: This form is not for online submission. Please print this form and bring completed form to your office visit.

history form

 

Medical History

PATIENT NAME__________________________ Date_________________

Past Medical History:

Please tell Dr. Baker if you have ever been treated or taken medication for: (circle the disease/disorder)

High Blood Pressure Stroke  Heart Disease
Ulcers Cancer  Alcoholism
Diabetes Gout Depression
Asthma Hepatitis Anxiety Disorder
Emphysema Seizures Mental Illness
Chronic Bronchitis Migraine HIV/AIDS
Kidney/Urinary Trouble Thyroid Disease Reaction to anesthesia
Drug or alcohol addiction Tuberculosis Malignant Hyperthermia
Blood Disorders (Sickle Cell Disease or Trait, Thalassemia, etc.) Prostate problems Bleeding disorders
(Hemophilia, VonWillebrand's)
     

Other disease or disorder ______________________________________________________

 

Have you ever smoked? ¨ NO ¨ YES     How many packs per day?____

If you have quit smoking, when did you quit?________

Do you drink alcohol? ¨ NO ¨ YES     How much?______________

If you don’t drink now, did you drink alcohol in the past? ¨ NO ¨ YES

Are you allergic to latex or any medications? ¨ NO ¨ YES If so, please list:________________________________________________________________________

_______________________________________________________________________________

List all surgeries you have had with the approximate date___________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

  Please list your medications:

Medicine Dose (How much) Frequency (How many times a day or week)
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     


 

Review of Systems Screening

Please circle any problems listed below you have been experiencing recently:
General body lumps unexpected weight loss loss poor appetite tiredness/weakness > 3 weeks  
Head/Neck Sore throat  ear ache dizziness lightheadedness runny nose headaches
Cardiovascular chest pain palpitations discoloration of foot, hand, toes, fingers    
Respiratory shortness of breath wheezing cough more than 3 weeks coughing up blood or green/yellow sputum cold symptoms
Gastrointestinal belly pain diarrhea constipation indigestion/heartburn  
Genitourinary burning urination excessive urination blood in urine difficulty starting or stopping urination night urination
Musculoskeletal pain in joints swelling of joints back pain stiffness muscle/tendon ache
  giving way of knee or ankle joint locking popping      
Skin rash sores bleeding moles easy bruising psoriasis
 Neuro/psych seizures numbness burning pain decreased sensation paralysis
  frequent crying sadness unexplained panic tremor    
Endocrine unusual thirst  frequent urination increased appetite loss of hair hot flushes
Hem/lymp easy bruising bleeding problems after tooth extraction or surgery severe bleeding problems with periods    
Allergy/immun. allergy to latex frequent infections      

                                                  

Family History arthritis hypertension heart disease diabetes

Additional Comments: