Patient Information


(Please list all and include side(s) affected)



Gender Identity, Preferred Pronoun, and Sexual Orientation

The following section is optional. Regulatory standards mandate this information be offered to all patients for disclosure.

Race and Ethnicity

Social History













Pharmacy Information

Please provide as much information as possible in regards to your pharmacy, including the name, number, city/cross streets and/or zip code. This will help us better find your correct pharmacy location.

Current Medications

# Medication Dosage Frequency
Add Medication     Delete Medication


Allergies

# Allergy Reaction
Add Allergy     Delete Allergy



Previous Surgeries/Hospitalizations

Surgery Yes No
Tonsillectomy
Appendectomy
Gallbladder Removal
Hysterectomy
Hernia
Spinal Surgery
Heart Surgery
Orthopedic Surgery (1)
Orthopedic Surgery (2)
Orthopedic Surgery (3)
Other Surgery (1)
Other Surgery (2)



Medical History (Illness)

Illness Yes No Date
Acid Reflux
Anemia
Asthma
Bleeding Tendency
Blood Clots
Cancer
Deafness/Hearing Loss
Depression
Dermatitis
Diabetes, Type 1
Diabetes, Type 2
Gout
Heart Attack
Hepatitis
High Blood Pressure
High Cholesterol
HIV
Hyperthyroidism
Hypothyroidism
Irregular Heart Rhythm
Lung Disorders
Seizures
Sinus Problems
Stroke
Tuberculosis
Ulcers
Other (describe)

Medical History (Present Review of Symptoms)

Present Review of Symptoms Yes No Date
Abdominal Pain
Balance/Coordination
Chest Pain
Constipation
Corrective Lenses
Cough
Diarrhea
Dizziness
Double/Blurred Vision
Enlargement of Lymph Nodes
Fatigue
Fever
General Ill Feeling
Hallucinations
Headaches
Incontinence
Loss of Appetite
Loss of Muscle (Atrophy)
Memory Loss
Numbness in Arms/Legs
Painful Urination
Rashes/Lesions/Ulcers of Skin
Shortness of Breath
Skin Temperature Changes
Sleep Disturbances
Weight Loss

Family History


Disease Yes No
Osteoarthritis
Rheumatoid Arthritis
Hypertension
Heart Disease
Muscular Disease
Endocrine Disease
Diabetes
Cancer

Physician Information

Patient Sign-Off

Electronically Signed by:

 

©2018 All Rights Reserved Methodist Sports Medicine