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.

Medical History, page 2

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?     NO     YES     How much?                  

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

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

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Please list all surgeries you have had with approximate dates

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Please list your medications:

Name                                     Dose  (how much)                            Frequency (how often)