Name: _________________________________ dob: ________________________

NAME: _________________________________ DOB: ________________________
You are here for what body part (what side)? __________________ How long has it hurt?_______________
Date of Injury: ______________________________ Are you Right-Handed or Left-Handed? ________
If injury, briefly explain what happened: ___________________________________________________
What treatments have you tried in the past? (CIRCLE ALL THAT APPLY) Tylenol Ibuprofen Aleve Supartz
Ice Heat Elevation
Surgery Brace Biofreeze Steroid Injection Percocet (Oxycodone) Vicodin (Hydrocodone) Mobic (Meloxicam) Ultram (Tramadol) Pharmacy: __________________ City and Street:__________________ Who Referred you here? ______________________ Is this WORKER’S COMPENSATION? Yes or No Primary Care Doctor: _______________________ City/Practice Name: ___________________________ Specialist Doctor Names:_____________________________ Dentist: ____________________________ Circle any health problems YOU have or are being treated for.
History of Heart Attack History of Stroke Heart Disease High Cholesterol History of Blood Clot Arthritis Gout Rheumatoid Arthritis Lupus History of Cancer: What type and when?___________ Please list your current medications with dosages and how often you take them.
If you have a list or actual medicines, give it to nurse later.
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Are you allergic to any medicines? Yes or No If so please list:______________________________________
Do you have a metal allergy? ______
Circle any problems your immediate family has a history of.
History of Heart Attack History of Stroke Heart Disease High Cholesterol History of Blood Clot Arthritis Gout Rheumatoid Arthritis Lupus History of Cancer Do you smoke? Yes or No How much per day? __________ Did you used to smoke? Yes or No Do you drink alcohol? Yes or No Please circle how much/often: Rarely Occasionally Socially Moderately Are you retired? Yes or No Do you work? Yes or No Who lives with you? ______________________ Circle: Married Divorced Widowed Single Please list all your past surgeries and years performed.
CIRCLE ONLY WHAT YOU HAVE HAD IN THE PAST 12 HOURS
Appetite Loss, Chills, Fatigue, Fever, Weakness, Weight Gain and Weight Loss. Bruising, Itching, Rash, Wound. Blurred Vision, Diplopia (double vision), Eye Pain, Eye Discharge, Light sensitivity, Eye Redness, Hearing Loss, Ear Pain, Nose Bleed, Nasal Congestion, Throat Pain and Difficulty Swallowing. Neck Swelling. Cough, Difficulty Breathing and Hemoptysis (coughing up blood) Chest Pain, Edema, Elevated Blood Pressure, Orthopnea (shortness of breath when lying down), Palpitations, Shortness of Breath. Abdominal Pain, Constipation, Diarrhea, Bloody Stool, Nausea and Vomiting. Blood in Urine, Painful urination, Frequency and Blood in urine. Dizziness, Fainting, Headaches, Numbness, Seizures. Anxiety, Depression, Hallucinations. Thank you for filling this out so we may better serve you.

Source: http://www.randolphorthopedics.com/wp-content/uploads/2012/12/Allscripts-Patient-Intake-Form.pdf