James K. Baker, M.D.
Lone Star Orthopedics, PA
Please note: this form is not for on-line submission. Please print this page and bring this to the office for your visit.
Patient name_______________________________ (please print) Date of birth_____/_____/_______
Past Medical History please tell us if you have ever been treated or taken medication for (circle the disease or disorder):
High blood pressure Coronary artery disease (clogged heart arteries) Heart attack (myocardial infarction)
Atrial fibrillation Heart arrhythmia Stroke Ulcers Diabetes Cancer (what type?_________________)
Gout Depression Depression Anxiety disorder Claustrophobia Mental illness
Emphysema Bronchitis COPD Asthma Other lung disorder (what type?_____________________)
Chronic kidney disease/kidney failure Prostate problems Reaction to anesthesia (what happened?_______)
Blood disorders (sickle cell disease or trait, Thalassemia, leukemia, lymphoma, hemophilia, VonWillebrand's)
HIV/AIDS MRSA infection Drug or alcohol addiction Seizures Neuropathy Migraine headaches
Signature of patient or guardian Date