Medical History

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