Please note: This form is not for online submission. Please print this page and bring it to the office for your visit.

Lone Star Orthopedics

James K. Baker, M.D. 

512-353-8658


Medical History Form

Patient name       _______________________________________


Date of birth        _______/_______/______


Medical history - please tell us if you have ever been treated or taken medication for (circle disease or disorder):


High blood pressure     Coronary Artery Disease (clogged heart arteries)     Heart attack (myocardial infarction)     Irregular heartbeat     Atrial fibrillation


Stroke     COPD     Emphysema/bronchitis     Asthma     Other lung disorder (what type?___________________________)       Sleep apnea         Need for CPAP/BPAP


Bleeding or blood clotting disorders   (Von Willebrand's     Hemophilia     Sickle cell disease or trait     Thalassemia     Leukemia     Lymphoma 


           Leiden deficiency     personal history of blood clots


Chronic kidney disease     Kidney failure     Prostrate cancer     Enlarged Prostrate (BPH)    Peripheral vascular disease (clotted arteries in legs or arms)


Diabetes     Gout     Osteoporosis/osteopenia    GERD/gastroesophageal reflux/heartburn


 Cancer (what type please and what treatment?    ______________________________________________________________________________________


Reaction to anesthesia     Depression     Anxiety disorder      Mental illness     Claustrophobia     Drug or Alcohol Addiction


Migraine headaches     Neuropathy     Seizures     HIV/AIDS    MRSA infection     Liver disease or cirrhosis


Other disease or disorder?  _____________________________________________________________________________________________________________



Have you ever smoked?     NO          YES, but I quit in ____________    YES, I smoke  ________ packs per day

Do you take oral tobacco or snuff?     NO      YES


Do you drink alcohol?   YES       NO


Are you allergic to any medications?     NO     YES

If yes, please list__________________________________________________________________________________________________________________________


Please list surgeries that you had with approximate dates

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Please list your Medications (or bring in a prepared list)

Name                   Dose (mg, drops, etc.)           Frequency  (how often) 


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