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:
Please list all surgeries you have had with approximate dates
Please list your medications:
Name Dose (how much) Frequency (how often)