Medical History

Patient Name

Reason for today's visit

Pain

Swelling

Numbness

Ingrown nail

Wart

Corn/Callus

Other

How long have you had this condition?

Symptoms are

Improving Worsening Unchanged

Describe your pain:(Check all that apply)

Sharp

Dull

Aching

Burning

Tingling

Other

If other, please indicate

Symptoms worse when

Standing

Walking

Sitting

Sleeping

Other

Symptoms are worse

Morning Night All day

Previous treatments include

Rest

Elevation

Ice/Heat

Over-the-counter inserts

Injections

Brace/Bandage

Surgery

Medication

Have you been treated by another physician for the conditions

Yes No

Name of Doctor

When

Are you receiving

Home Health/Aide Hospice In Nursing Facility Physical Therapy None

Allergies: (Check all that apply)

None

Adhesive Tape

Aspirin

Codeine

Novocaine

Sulfa Drugs

Penicillin

Other

Do you have a Pain Management Doctor

Yes No

If yes, please indicate Dr.

Medications: Are additional medications listed on the back of the Financial Sheet?

Yes No

If yes, please add medication(s)

Add Medication

If tuberculosis is checked, please indicate type

If Cancer is checked, please indicate type

Have you ever been exposed to the AIDS virus

Yes No

Do you wear glasses / contacts?

Yes No

Family Medical History

Gout

Mother Father

Diabetes

Mother Father

High Blood Pressure

Mother Father

Rheumatoid Arthritis

Mother Father

Fibromyalgia

Mother Father

Previous Surgeries/Hospitalizations

Hysterectomy

Date

Tubal Ligation

Date

Joint Replacement

Location

Date

Other

If other, please indicate surgery

Date

Social History

Height

Weight

Shoe Size

Are you pregnant or a chance you could be pregnant?

Yes No

Due Date

Do you smoke

Yes No Quit

Packs/day

How many years

Do you drink alcohol

Yes No

How much?

Claustrophobic

Yes No

Do you use recreational drugs?

Yes No

Pacemaker or Defibulator

Yes No

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