BP ____/_______ Pulse _______ Temp _______
O2 Sat ________
DOI _________________
Clinician Signature: ________________________________

Name__________________________________ DOB:___________ Age__________ Chart #___________ Date___________ Primary Care Doctor________________________ Referring Doctor__________________ Height________ Weight________ Drug Allergies: (Please indicate by checking the boxes below.)
□ Local anesthetics (Novocain etc.) □ Penicillin □ Keflex □ Erythromycin □ Other antibiotic: _____________ □ Sulfa drugs □ Aspirin □ Narcotics (codeine, morphine etc.) □ Other painkillers (Percocet, Oxycontin etc.) □ Latex □ Eggs/Yolk □ Sulfites □ Tetracycline □ Iodine/shellfish □ NSAIDs (Ibuprofen etc.) Please specify any others: _____________________________________________________________________ Please specify type of reaction:_________________________________________________________________
Medicines: (Please list any medications or supplements that you take REGULARLY, with dose/frequency.)
_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Family History:
Is there a history of any of the following conditions in your family? Please circle and state which family member is/was effected. Detail below: Alcoholism Anemia Arthritis Asthma/COPD Bleeding Disorder Blood Clots CAD Stroke Cardiovascular Diseases Cancer Diabetes Heart Attack Hypertension Osteoporosis Osteoarthritis _____________________________________________________________________________________________ _____________________________________________________________________________________________ Social History:
Occupation_____________________________________Employer___________________________________________ Marital Status ________________________________ Lives with (circle all that apply): Spouse / Children / Parents / Mother / Father / Grandparents / Foster Care /Roommates Social Habits:
Tobacco- Do you smoke or use tobacco products?__________ Circle all that apply: Cigarettes / Cigars / Chewing Tobacco
How much?___________/day. Number of Years using ________ If you quit, when?___________ Recreational Drugs – Do you use recreational/illicit drugs?___________ Which drugs? ____________________________ Alcohol- Do you use alcohol?_________________How much?_______/week. If you quit, when?________________ Exercise- Do you exercise on a regular basis? Yes / No Type of Exercise: _________________________________ Have you ever had a pneumovax shot? Yes/ No Review of Systems:
Have you experienced any of the following in the last few weeks or months?
Please circle the complaint and detail below. If you have no complaints in a category, please circle “NONE” indigestion/heartburn nausea/vomiting blood in stool abdominal pain/cramps ulcers NONE frequent thirst frequent urination hot-cold symptoms weight loss frequent fever loss of appetite Ear/Nose/Throat: hearing loss hoarseness trouble swallowing Cardiovascular: chest pains irregular heart beat palpitations chronic cough shortness of breath wheezing painful urination blood in urine kidney problems frequent headaches dizziness seizures leg or arm weakness drug or alcohol problems depression sleep disorders Heme/lymphatic: abnormal bruising abnormal bleeding hemophilia NONE _____________________________________________________________________________________________ _____________________________________________________________________________________________ Medical Conditions: (Please circle any of the listed medical conditions that you have been or are currently being treated for.)
Abnormal Heartbeat Anemia Asthma Autoimmune Disease Bleeding Disorder Blood Clot/DVT Diabetes- controlled with pills Diabetes- controlled with insulin GI Bleed Heart Attack Heart Failure Hepatitis A Hepatitis B Hepatitis C High Blood Pressure HIV Irregular Heartbeat Kidney Failure Liver Disease Lung Disease MRSA Paralysis Seizures Stroke Sleep Apnea CPAP Use Pregnancy- estimated due date: _________ Other Condition Not Listed:________________________________ *Have you or a family member ever been diagnosed with a blood clot in a leg or a lung? ____YES ___NO
If “Yes”, who had the clot? ____________________________
Are you under the care of a Cardiologist: ____ Yes ____No Name: _______________________________
Contact Info: __________________________
Have you ever had problems with Anesthesia in the past?
If yes, please explain: _______________________________________________________________________

Please list Surgeries/Complications/Diagnoses along with the DATE
1.___________________________________________________________________________________ 2.___________________________________________________________________________________ 3.___________________________________________________________________________________ 4.___________________________________________________________________________________ 5.___________________________________________________________________________________ Patient Signature:_________________________________________________Date:__________________________ Clinician Signature:_______________________________________________Date:__________________________ MD/PA:________________________________________________________Date:__________________________

Source: http://www.vsortho.com/sites/all/themes/vso/pdf/EMRHealthHistory.pdf


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