MEDICAL HISTORY QUESTIONNAIRE

DIRECTIONS: PLEASE READ AND ANSWER ALL QUESTIONS CAREFULLY AND COMPLETELY.

I. PERSONAL INFORMATION:
Last Name *
First Name *
Middle Initial *
Date of Birth *

II. REFERRAL INFORMATION
Did a Doctor refer you here today? * Yes No
Doctor's Name  
Did you Bring XRAYs? * Yes No
Doctor's Name who released XRAYs  
Did you bring outside records? * Yes No
Doctor's Name who released records  
Do you have a family Doctor * Yes No
Family Doctor's Name  
Did a Lawyer Advise you to come here? * Yes No
Lawyer's Name  
What is your Reason for this Visit (body part) *
Specific Date Symptom Began? *
Where you treated by another Doctor for this Condition? If so what treatment did you receive?  
If an injury did this happen at work?   Yes No
Car Accident?   Yes No
How did injury occur?  
Date of injury  

III. CURRENT MEDICAL INFORMATION
Allergic to Penicillin? * Yes No
Allergic to Sulfa Drugs? * Yes No
Other drugs Allergies  
Foods Allergies  
Other Allergies  
Most recent Tetnus Booster *
List all regular prescriptions you are currently taking  

IV. FAMILY HISTORY:
Have any of your Blood Relatives had:
Asthma? * Yes No
Relationship  
Diabetes? * Yes No
Relationship  
Heart Disease? * Yes No
Relationship  
Heart Attack? * Yes No
Relationship  
Scoliosis? * Yes No
Relationship  
Osteoporosis? * Yes No
Relationship  
Rheumatoid Arthritis? * Yes No
Relationship  
Degenerative Arthritis? * Yes No
Relationship  
Sudden Death Episode? * Yes No
Relationship  
High Blood Pressure? * Yes No
Relationship  
Blood Disease? * Yes No
Relationship  
Bleeding Disorders? * Yes No
Relationship  

V. PERSONAL GENERAL MEDICAL HISTORY:
High Blood Pressure? * Yes No
Explanation  
Diabetes? * Yes No
Explanation  
Heart Disease? * Yes No
Explanation  
Heart Attack? * Yes No
Explanation  
Weight Gain/Loss? * Yes No
Explanation  
Rashes? * Yes No
Explanation  
Swelling? * Yes No
Explanation  
Numbness or Tingling? * Yes No
Explanation  
Gout? * Yes No
Explanation  
Shortness of Breath? * Yes No
Explanation  
Wheezing? * Yes No
Explanation  
Cancer? * Yes No
Explanation  
Emotional Problems? * Yes No
Explanation  
Glaucoma? * Yes No
Explanation  
Bleeding Disorders? * Yes No
Explanation  
HIV/AIDs? * Yes No
Explanation  
Hepatitis C? * Yes No
Explanation  
Thyroid? * Yes No
Explanation  
Scoliosis? * Yes No
Explanation  
Osteoporosis? * Yes No
Explanation  
Rheumatoid Arthritis? * Yes No
Explanation  
Degenerative Arthritis? * Yes No
Explanation  
Sudden Death Episode? * Yes No
Explanation  
Ulcer? * Yes No
Explanation  

ULCER?
Can you take Aspirin? * Yes No
Explanation  

SOCIAL HISTORY:
Smoke? * Yes No
If yes, how much per day/week?  
Drink Alcohol? * Yes No
If yes, how much per day/week?  

SURGERIES?
Appendix? * Yes No
C-Section? * Yes No
Ears? * Yes No
Gall Bladder? * Yes No
Hernia? * Yes No
Hysterectomy? * Yes No
Thyroid? * Yes No
Tonsils? * Yes No
Tubal Ligation * Yes No
Other