Download Name: DOB: Chart: JEWETT ORTHOPAEDIC CLINIC

Name:
DOB:
Chart:
Date of Visit
JEWETT ORTHOPAEDIC CLINIC
Medical History - Page 1
Age:
Height:
Weight:
Primary Physician:
Please note, items left blank indicate a negative response.
PAST MEDICAL HISTORY
Bleeding disorders
Blood clots/DVT
Stroke
Seizures
Sleep apnea
Asthma/Emphysema
High blood pressure
Heart Disease
Arrhythmia
Anemia
Diabetes
Thyroid disorders
SURGICAL PROCEDURES:
Tonsils
Appendix
Thyroid
Indicate all medical conditions you have experienced.
None
Uterus
Breast
Vascular
Prostate
Hernia
Other (list in space below)
Indicate all medical conditions experienced by any parent, sibling, or child
None
Cancer
Stroke
Seizures
Osteoporosis
Rheumatoid arthritis
Gout
Fibromyalgia
Birth defects
Other (list in space below)
Indicate all surgical procedures (include approximate dates).
None
Heart
Colon
Gallbladder
FAMILY HISTORY:
Liver disorder
Stomach ulcers
Kidney problems
Prostate enlargement
Cancer
Glaucoma
High blood pressure
Heart disease
Diabetes
Kidney problems
Bleeding disorders
Blood clots/DVT
Osteoporosis
Birth defects
Anesthesia complications
SOCIAL HISTORY:
Occupation:
Marital status:
Living alone:
Tobacco use:
Cigarettes
Other:
Alcohol use:
Beer
Single
Married
Yes
No
Never
Previous
packs per day:
None
Wine
REVIEW OF SYSTEMS:
Fevers/Night sweats
Shaking/Chills
Recent weight loss
Bleeding gums
Frequent nosebleeds
Visual problems
Hearing problems
Dizziness/Fainting
Occasionally
Liquor
None
Student
Retired
Widowed
Divorced
with spouse
with family
Currently every day
number of yrs:
number of yrs:
Weekly
Daily
Disabled (when):
with other:
Currently some days
Quit when:
Quit when:
Quit when:
Indicate all symptoms that you are presently experiencing.
Frequent headaches
Morning cough
Shortness of breath
Coughing up blood
Hoarseness
Chest pain
Abnormal heartbeat
Ankle swelling
Nausea/Vomiting
Stomach pain
Blood in stools
Loose stools
Loss of appetite
Difficulty with urination
Pain/Burning on urination
Blood in urine
Rashes
Severe itching
Bruising/Bleeding easily
Calf cramps
Joint pain
Joint swelling
Loss of height
Irregular periods
Name:
DOB:
Chart:
Date of Visit
JEWETT ORTHOPAEDIC CLINIC
Medical History - Page 2
MEDICATIONS:
None
List all prescription and non-prescription medications and supplements.
Name of medication
ALLERGIES:
None
Strength/Dose
Frequency
Indicate all allergies you have to medications and foods.
Include reaction, i.e. nausea, vomiting, itching, rash, swelling, difficulty breathing
Penicillin
Sulfa
Aspirin
Codeine
Morphine
Iodine
Latex
Milk
Other - List below
Print name of patient (or authorized representative)
Signature of patient (or authorized representative)
Date
Name of Provider
Provider Signature
Date
Name:
DOB:
Chart:
Date of Visit
JEWETT ORTHOPAEDIC CLINIC
Medical History - Page 3
SUPERCONFIDENTIAL INFORMATION:
Indicate all conditions for which you have received treatment.
None
Mental health conditions (depression, anxiety, etc.)
Substance abuse (alcohol, narcotics, etc.)
Illegal drug use
HIV / AIDS
Sexually transmitted diseases (STD's)
Minor pregnancies (pregnancy under the age of 18)
If you have indicated any of the conditions above, please initial the corresponding categories listed below which will
authorize Jewett Orthopaedic Clinic to disclose that information to third parties for treatment or payment purposes
in the event that it is requested by said third parties or required by law
Initials:
Mental health information
Initials:
HIV/AIDS information
Initials:
Substance abuse information
Initials:
STD information
Initials:
Illegal drug use information
Initials:
Minor pregnancy information
Are you pregnant or could you be pregnant?
No
Yes
If yes, due date:
I HAVE READ AND UNDERSTAND THE INFORMATION IN THIS CONSENT. I AM THE PATIENT OR AUTHORIZED
TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS DOCUMENT VERIFYING CONSENT TO THE ABOVE TERMS.
Print name of patient (or authorized representative)
Signature of patient (or authorized representative)
Date
Reason patient is unable to sign and representative's relationship to patient or authority to sign on behalf of patient
Name of Provider
Provider Signature
Date