Download SLU Sports Medicine Medical History Form Page 1

Page 1
SLU Sports Medicine Medical History Form
Please fill out completely due to this being a part of your permanent medical record.
Name: _______________________________
Pregnant: Y / N
Age: ______
Date: _______________
SS#: _______________________
DOB: _______________ Right / Left Handed: _____
Date of Accident / Injury: ________
Telephone Numbers:
Home (
) ______ - _________ Cell (
) ______ - _________ Work (
Drug Allergies: ___________________________________
) ______ - _________
Height: ____________
Weight: ____________
Reason for Visit: ____________________________________________________________________________
Please describe the recent events of this current orthopaedic problem. Answer how long it has been a
problem, what makes it worse, and what makes it better:
_________________________________________________________________________________________
_________________________________________________________________________________________
Have you had/taken any of the following? (please circle all that apply)
Physical therapy
Other Injections (specify ________________________________)
Injections of cortisone
Advil, Motrin, Alleve, ibuprofen, other pain medications (specify _________)
Please list all current medications:
1.
2.
3.
4.
5.
6.
Past Surgeries: Please list in chronological order from oldest to newest and year of surgery.
1.
2.
3.
4.
Diagnostic Studies: List any you have had for this condition along with the date and place the study was
performed (MRI, CT, X-rays, EMG, etc)
1.
2.
3.
4.
Family Medical History: List medical illnesses affecting your immediate family (parents, siblings)
Disease
Family Member
Disease
Family Member
1.
3.
2.
4.
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Social History: Check and fill in the blanks
Married ____
Single ____
Alcohol ____
Tobacco ___
Divorced ____
Live Alone ____
# of Children ____
Occasional ____ Moderate ____
Heavy ____
History of drug abuse _____
Years used ____Packs/day ____
Recreational drugs ________
Years used _____
General History: Please Check if any apply.
General-Skin-Endo:
___
___
___
___
___
___
___
___
___
___
___
___
1
2
3
4
5
6
7
8
9
10
11
12
Weight change
Fever or chills
Night sweats
Urinary frequency
Bleeding
Lumps of masses
Dizziness or fainting
Itching or rash
Diabetes Mellitus
Thyroid problems
Cancer
Other
Gastrointestinal:
___
___
___
___
___
1
2
3
4
5
1
2
3
4
5
Backache
Joint pain
Joint swelling
Fractures
Other
___
___
___
___
___
1
2
3
4
5
1
2
3
4
Bleeding disorders
Anemia
Platelet problems
Other
___
___
___
___
___
1
2
3
4
5
Urinary tract infections
Incontinence
Venereal diseases
Menopause
Other
Neurologic:
Heart diagnosis / pain
Hypertension
Mitral valve prolapse
Thrombophlebitis
Other
___
___
___
___
___
1
2
3
4
5
Ear-Nose-Throat-Eye:
___
___
___
___
___
___
___
1
2
3
4
5
6
7
Hematologic Disorders:
___
___
___
___
Dysphagia (swallowing difficulties)
Nausea & vomiting
Jaundice
Hepatitis
Other
Cardiovascular:
Musculoskeletal:
___
___
___
___
___
Genitourinary:
Visual changes
Hearing problems
Tinnitus
Dentures
Bleeding gums
Hoarseness
Other
Mental Health:
___
___
___
___
1
2
3
4
Seizures
Paralysis
Numbness
Weakness
Other
Respiratory-Allergy:
___
___
___
___
___
___
___
___
1
2
3
4
5
6
7
8
Cough / sputum
Rheumatic fever
Tuberculosis
Pleurisy / pneumonia
COPD / Emphysema
Asthma
Shortness of breath
other
Depression
Trouble concentrating
Anxiety attacks
Other
Other medical conditions not listed above:
1. _______________________________________________________________________________
2. _______________________________________________________________________________
Description of current employment / occupation: -________________________________________________
Is injury work related? ___ Yes ___ No Current litigation regarding injury: ___ Yes
___ No
Which physician referred you to our office? _____________________________________________________
Name and phone number of primary care physician: ______________________________________________
______________________________________________
Patient’s Signature
___________________
Date