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PRACTICE NAME NEW PATIENT MEDICAL HISTORY FORM Height: Weight: Race: African American Asian Caucasian Native American/Alaskan Pacific Islander Other Unknown Decline to Answer Ethnicity: Hispanic Non-Hispanic Unknown Decline to Answer Preferred Language: English Spanish Chinese Other Preferred Pharmacy: Referral Source: Doctor (name): Other (ex. Google search): Chief Complaint Dominant Hand: Right Left Ambidextrous Description of Symptoms: (select only ONE primary symptom and ONE affected area) Pain Numbness/Tingling Fracture Stiffness Other: Shoulder Right Left Pelvis Right Left Neck Upper Arm Right Left Hip Right Left Upper Back Elbow Right Left Thigh Right Left Mid Back Forearm Right Left Knee Right Left Low Back Wrist Right Left Lower Leg Right Left Buttocks Hand Right Left Ankle Right Left Tail Bone Thumb Right Left Foot Right Left Index Right Left Great Toe Right Left Middle Right Left 2nd Digit Right Left Third Right Left 3rd Digit Right Left Little Right Left 4th Digit Right Left Pain radiates from/to: (ex. from low back to right leg) History of Present Illness 1. Is your problem the result of an injury or accident? 5th Digit Right Left No Injury Injury Injury at Work Auto Accident Sport Injury Prior Surgery How long have the symptoms been present? (ex. 2 days, 4 months) Describe the onset: Acute (sudden) Chronic condition (>3 months) Onset Date: (mm/dd/yyyy) 2. Are you represented by an attorney? Yes No Attorney Name: Will there be any legal actions with respect to this problem? Yes No 3. Have you had a problem like this before? Yes No Describe: 4. Have you been seen in an ER for this problem? Yes No Treating ER: (ex. St. Luke s Health) Date: (mm/dd/yyyy)

Page 2 History of Present Illness (continued) 5. Rate the pain (10 being the most pain): 0 1 2 3 4 5 6 7 8 9 10 6. Do the symptoms wake you from sleep? Yes No 7. Please describe the symptoms: Sharp Dull Stabbing Throbbing Aching Burning Shooting 8. What is the timing of the symptoms? Constant Intermittent (comes and goes) 9. Is the problem getting better or worse? Getting better Getting worse Unchanged 10. What makes the symptoms worse? Squatting Kneeling Sitting Bending Stairs Twisting Moving Lying in bed Running Walking Athletics Standing Gripping Lifting Reaching Overhead 11. Are there any other symptoms associated with this problem? Redness Bruising Swelling Numbness Stiffness Limping Clicking Locking Popping Tingling Weakness Giving way Prior Testing / Treatment Have you had any prior tests for this problem? None X-rays MRI CT Scan Nerve Test (EMG/NCV) Bone Scan Have you had any prior treatment for this problem? Yes No Type of treatment Status of symptoms after treatment (select only those that apply) Date of treatment Ice Improved Worsened Unchanged Heat Improved Worsened Unchanged Rest Improved Worsened Unchanged NSAIDs Improved Worsened Unchanged Muscle Relaxers Improved Worsened Unchanged Chiropractor Improved Worsened Unchanged Physical Therapy Improved Worsened Unchanged HomeExerciseProgram Improved Worsened Unchanged Surgery Improved Worsened Unchanged Injections Improved Worsened Unchanged Bracing Improved Worsened Unchanged TENS unit Improved Worsened Unchanged Other/Comments:

Page 3 Select all previous hospitalizations/surgeries: None Aneurysm (Brain) Surgery Hysterectomy Orthopedic on side: Right Left Aortic Bypass / Vascular Surgery LAP Band / Gastric Bypass Surgery Arthroscopy: Knee Appendectomy Lumpectomy Arthroscopy: Shoulder Cataract (Eye) Surgery Mastectomy Carpal Tunnel Release Cholecystectomy (Gallbladder) Malignancy/Cancer Rotator Cuff Repair Heart Surgery Stents Total Hip Replacement Hernia Repair Total Knee Replacement Total Shoulder Replacement Spinal Surgery - Indicate Level: Other Surgery Other Orthopedic Surgery Medical Questions Mark all that currently apply: Metal in body Claustrophobic Pregnant Sleep Apnea Uses a CPAP Snores Are you taking blood thinners? Yes No Review of Systems Please indicate if you have experienced any of the following symptoms in the last 6 months? None for all None Comments 1) CON Weight Loss Loss of Appetite Fatigue 2) EYE Blurred Vision Double Vision Vision Loss 3) ENT Hearing Loss Hoarseness Trouble Swallowing 4) CV Chest Pain Palpitations 5) RS Chronic Cough Pneumonia Shortness of Breath 6) GI Heartburn, Ulcers Nausea, Vomiting Blood in Stool 7) GU Painful Urination Blood in Urine Kidney Problems 8) SK Frequent Rashes Skin Ulcers Lumps Psoriasis 9) NEU Frequent Falls Loss of Coordination Numbness Change in Bowel Change in Bladder Dizziness 10) PSY Depression/Anxiety Drug/Alcohol Addiction Sleep Disorder 11) ENDO Fever Heat or Cold Intolerance Night Sweats 12) HEM Easy Bleeding Easy Bruising Anemia

Page 4 Family History Have any direct relatives had any of the following disorders? None for all Father None Diabetes Heart Disease Hypertension Social History Do you smoke tobacco? Current, every day smoker Current, some day smoker Former smoker Never Pain Diagram Mother None Diabetes Heart Disease Hypertension Sibling None Diabetes Heart Disease Hypertension Heavy tobacco smoker Light tobacco smoker Do you drink alcohol? Daily Occasionally Rarely Never Marital Status: Married Single Divorced Widowed Domestic Partnership Are you currently working? Yes No Retired Disabled If no, what date did you last work? Please list work restrictions, if any: Occupation: Employer: Student

Page 5 Do you have any allergies? Yes No If Yes, please list below: Medication, Relevant Food, or Seasonal Reaction Latex allergy? Yes No Please list all medications you take on a regular basis: None Medication Dosage and Frequency (e.g. 20 mg, once/day) Do you have a personal history of any of the following? None Aneurysm Where: Emphysema Kidney Disease Angina (Chest Pain) Epilepsy Kidney Stones Arthritis Type: Heart Attack MRSA Infection Asthma Hepatitis Type: Pacemaker Bone or Joint Infections HIV / AIDS Phlebitis (Blood Clots) Cancer Type: High Cholesterol Pulmonary Embolism Chemotherapy / Radiation Hypertension Reaction to Anesthesia Type: COPD Hyperthyroidism Seizures Congestive Heart Failure Hypothyroidism Stomach Ulcers Diabetes Type: Last A1C: Stroke / TIA Tuberculosis Please list any other conditions or details of conditions marked above: Signature Date

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