Medical History Form

Front Range Center for Spine & Sports Medicine

Name:

Date:

Age:

Height:

Weight:

MEDICAL HISTORY

Chief Complaint:

Duration of Problem:

Days:

Weeks:

Months:

Years:

Date of Injury:

Was this a(n):

Auto Accident Work Injury Recreational Injury No Known Reason Other

if Other is Selected, Please describe:

Please describe how problem began:

Please Check all that apply - Pain is:

Shooting Pain

Stabbing

Burning

Electricity

Dull

Achy

Do you have neck pain?

Yes No

Do you have low back pain or sciatica?

Yes No

Do your hands tingle at night?

Yes No

Have you had any operations?

Yes No

Operation:

Date:

Successful:

Yes No

Add more

What medications, If any, Do you take at this time?

Add more

Do you have any allergies to medicine?

Yes No

if yes, Please list:

Add more

Are you involved in litigation or a law suit?

Yes No

Do you have any other Medical Illness?

Add more

Do you smoke?

Yes No

If so, how many packs per day?

Do you drink alcoholic beverages?

Yes No

If so, how much?

If you have not done so already, please fill out the other forms after submission of this one. All 4 are required for new patients.

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