Accessibility Tools

Current Medication List

  • LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: Prescription and over the counter medications, herbals, vitamin/mineral/dietary supplement. ALL FIELDS ARE REQUIRED

    • Name of Current Medication (example: Aspirin tablet)
    • Dosage (example: 325 mg)
    • Frequency/Route of Administration (example: 3 times daily orally)
    • Length of Use
  • Medical disorders

  • If you have had any of the following, Place Mark inside boxes No Medical History Stroke Sleep Apnea AIDS/HIV Cancer Breast Gout Alcoholism Cancer Colon Heart Attack Alzheimer’s Cancer Lung High Blood Pressure Anemia Cancer Prostate Hepatitis Rheumatoid Arthritis COPD Kidney Disease Asthma Depression Osteoarthritis Blood Clot Leg Diabetes Seizures Blood Clot Lung Drug Abuse Ulcers, Bleeding Blood thinners (Coumadin, Plavix, aspirin, etc) Other Disease (list below)
  • Surgical History

  • If you have had any of the following, Place Mark inside boxes No Surgical History Reported Cardiac (Heart) Carpal Tunnel Left Wrist Carpal Tunnel Right Wrist Arthroscopy Left Elbow Arthroscopy Right Elbow Arthroscopy Left Shoulder Arthroscopy Right Shoulder Arthroscopy Left Ankle Arthroscopy Right Ankle Arthroscopy Left Knee Arthroscopy Right Knee Arthroscopy Left Hip Arthroscopy Right Hip Left Hip Replacement Right Hip Replacement Left Knee Replacement Right Knee Replacement Spinal Fusion Laminectomy Fracture Surgery Other Surgery (list in the box below)
  • Family History

  • If any family Member below has any of the following history, Place Mark inside Circles

  • Father Medical History AIDS/HIV Diabetes Kidney Disease Anemia Gout Liver Disease Blood Clots Heart Attack Muscle Disease Cancer Hemophilia Osteoporosis Coronary Artery Disease Hypertension Rheumatoid Arthritis Osteoarthritis
    Mother Medical History AIDS/HIV Diabetes Kidney Disease Anemia Gout Liver Disease Blood Clots Heart Attack Muscle Disease Cancer Hemophilia Osteoporosis Coronary Artery Disease Hypertension Rheumatoid Arthritis Osteoarthritis
    Sibling Medical History AIDS/HIV Diabetes Kidney Disease Anemia Gout Liver Disease Blood Clots Heart Attack Muscle Disease Cancer Hemophilia Osteoporosis Coronary Artery Disease Hypertension Rheumatoid Arthritis Osteoarthritis
  • Review of Systems

  • If you have any of the following, Please Place Mark inside boxes

  • Constitutional Weight Loss/Gain Weakness Fatigue Fever
  • Cardiovascular High Blood Pressure Chest Pain Rheumatic Fever Palpitations Has Pacemaker
  • Musculoskeletal Joint Pain Arthritis Muscular Weakness Stiffness Muscular Pain
  • Eyes Glasses or Contacts Blurred Vision Glaucoma Cataracts Excessive Tearing
  • Skin Rashes Sores Lumps Dryness Itching
  • Blood or Lymph Anemia Easy Bruising Easy Bleeding Swollen Glands
  • Ear Nose Mouth Throat Ears Ringing Earaches Hearing Aid Frequent Colds Nasal Discharge Hay Fever Nosebleeds Dentures Bleeding Gums Frequent Sore throats
  • Neurological Headache Dizziness Seizures Loss of Sensation Vertigo
  • Gastrointestinal Heart Burn Rectal Bleeding Abdominal Pain Gallbladder trouble Hepatitis
  • Respiratory Shortness of Breath Cough Wheezing Asthma Bronchitis
  • Genitourinary Blood in Urine Urinary Infections Kidney Stones Burning Urination Sexual Disease
  • Endocrine Thyroid Trouble Excessive Sweating Excessive thirst
  • Immunologic Reactions to Drugs Skin Rashes Reactions to Foods
  • Psychological Nervousness Depression Mood Changes
  • Social History: Please respond to the following by Placing Mark inside boxes

  • Substance Use
    Do you

  • Use Tobacco? Yes No Former
  • Use Alcohol? Yes No
  • Use Caffeine? Yes No
  • Use Illicit Drugs? Yes No
  • I do not use any of the above Yes No
  • Hand Dominance? Right Handed Left Handed
  • Females Only

  • Could you be pregnant? Yes No
  • Allergies

  • Do you have allergies to any of the following medications or substances No Known Allergies Codeines Penicillin Sulpha Drugs Iodine / Shellfish Vantin Ampicillin Depakene Amoxil Aspirin Keflex Ceftin Cefzil Suprax Septra Lamictal Tegretol Bactrim Pediazole Dilantin Novacaine Insulin Lidocaine
  • Other Allergies Latex IVP/X-Ray Dye Metal Egg/Avian (Bird)
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