PATIENT MEDICAL HISTORY

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Transcription:

M. Umar Burney, MD John Zavala, MD Danilo Volpini, MD Kushal Patel, MD Cary Tanamachi, MD Matthew Britt, DPM 1301 Summer Lee Drive, Rockwall, TX 75032 2300 FM 544 #120, Wylie, TX 75098 200 N. Virginia St, Terrell, TX 75160 375 N FM 548, Suite 100, Forney, TX75126 Phone: 972.771.8111 Fax: 972.771.8103 Sports Medicine / Joint Replaceme nt Shoulder Reconstruction / Podia try / Physical Therapy PATIENT MEDICAL HISTORY REFERRING DOCTOR OR PERSON: FAMILY DOCTOR: ARE YOU RIGHT OR LEFT HANDED?: RIGHT LEFT WHAT IS YOUR CURRENT JOB STATUS?: WORKING NOT WORKING LIGHT DUTY DISABLED PLEASE DESCRIBE WHAT KIND OF WORK YOU PHYSICALLY DO: DO YOU EXERCISE?: YES NO HOW MANY TIMES PER WEEK: CHIEF COMPLAINT WHAT PODIATRY PROBLEM ARE YOU SEEING THE DOCTOR FOR TODAY? WE NEED TO KNOW YOUR SPECIFIC COMPLAINT/FOOT PROBLEM.

Duration: Onset: Aggravating Factors (what makes it worse or better?): Previous or Current Treatment? Nature (circle all that apply): Location (circle all that apply): Course (circle all that apply): Sharp Left Intermittent Dull Right Constant Achy Ankle Progressive Burning Foot Varied Stabbing Toes: 1 st, 2 nd, 3 rd, 4 th, 5th Tingling Numbness CURRENT PROBLEM IS THE RESULT OF (CHECK ALL THAT APPLY): CAR ACCIDENT WORK RELATED INJURY OTHER DATE OF ACCIDENT OR INJURY: / / **EXACT DATE OF INJURY IS REQUIRED** IF YOU DO NOT REMEMBER THE EXACT DATE, PLEASE MARK A DATE THAT IS CLOSE TO THE DATE OF INJURY. **This date will be used to process your claim. If you do not specify this, your insurance could deny your claim. PLEASE DESCRIBE: MEDICAL HISTORY HAVE YOU EVER HAD OR CURRENTLY HAVE ANY OF THE FOLLOWING (PLEASE CHECK ALL THAT APPLY) : DIABETES ARTHRITIS HIGH BLOOD PRESSURE HEART DISEASE GOUT VASCULAR DISEASES PACEMAKER/SURGICAL IMPLANTS HEADACHES KIDNEY PROBLEMS OPEN WOUNDS CURRENT INFECTIONS HERNIA SEIZURES METAL IN BODY CANCER/TUMOR THYROID PROBLEMS CVA/STROKE ANXIETY PREVIOUS FRACTURES OSTEOPOROSIS DEPRESSION SUBSTANCE ABUSE HYPERSENSITIVITY TO HEAT/COL PRESENTLY PREGNANT HEPATITIS A HEPATITIS B HEPATITIS C HEART ATTACK RAYNAUD S WARTS TUBERCULOSIS HYPERTHYROID HYPOTHYROID HIGH CHOLESTEROL ANKLE SWELLING AUTOIMMUNE DISEASE BASAL CELL CARCINOMA BLEEDING DISORDER COPD CHARCOT FOOT CIRCULATORY DISORDER RHEUMATOID ARTHRITIS SHORTNESS OF BREATHE LIVER DISEASE KIDNEY DISEASE MITRAL VALE PROLAPSE OTHER PLEASE DESCRIBE ALL OF THE ABOVE THAT YOU HAVE CHECKED: HEIGHT: WEIGHT: SHOE SIZE: PATIENT SURGICAL HISTORY SURGICAL HISTORY

PLEASE LIST ALL THE SURGERIES YOU HAVE HAD IN THE PAST. PLEASE SPECIFY THE TYPE OF SURGERY AND THE YEAR THAT THE SURGERY WAS PERFORMED. PHARMACY INFORMATION PHARMACY NAME: PHARMACY PHONE: PHARMACY ADDRESS: ** REFILLS WILL ONLY BE DONE WHEN REQUESTED THROUGH THE PHARMACY OR WHEN YOU COME IN FOR AN APPOINTMENT. WE WILL NOT REFILL MEDICATION IF YOU CALL US AT THE OFFICE. ALSO PLEASE ALLOW THE PHARMACY AT LEAST 1-2 DAYS FOR A REFILL REQUEST SO PLEASE CALL IN YOUR REFILL REQUEST TO THE PHARMACY WHEN YOU HAVE ABOUT 1-2 DAYS WORTH OF MEDICATION LEFT OVER. ** ALLERGIES TO MEDICATIONS (PLEASE LIST ALL MEDICATIONS THAT APPLY): When was your last flu shot (date)? Have you received a Pneumonia vaccine (date)? SOCIAL HISTORY DO YOU HAVE CHILDREN: YES NO IF SO HOW MANY?: DO YOU LIVE ALONE?: YES NO DO YOU SMOKE?: YES NO IF SO HOW LONG?: HOW MANY PACKS PER DAY?: IF YOU QUIT SMOKING HOW LONG AGO DID YOU QUIT?: HOW LONG DID YOU SMOKE FOR?: HOW MANY PACKS PER DAY?: DO YOU DRINK ANY ALCOHOLIC BEVERAGES? IF SO WHAT KIND AND HOW OFTEN?: DO YOU HAVE ANY DRUG ABUSE OR ILLICIT SUBSTANCE ABUSE HISTORY?: YES NO IF SO, WHICH DRUGS AND HOW OFTEN?:

MEDICATIONS PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING W/DOSES AND DIRECTIONS WHERE APPLICABLE MEDICATION DOSE DIRECTIONS/COMMENTS

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