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Patient Information Form & Medical History
This form asks important information that we need to document for medical, legal, and insurance purposes. All information is confidential and kept as part of the medical chart in this office. Date: ___/___/_______ Primary Care MD: ___________________ Date of Birth: ___/___/_______ Age_____
Height ____'/______” Weight__________ lbs.
Did you bring x-rays or MRI films with you today? □Yes
Have you had x-ray or MRI done elsewhere in the last 3 months? □ Yes □No Where:________________
Who requested that you visit this office? ___________________
May we send a letter to the referring physician and / or your primary care M.D.? □ Yes □ No What body part(s) is/are involved? (Right / Left / both) ______________________________________ Are you right or left handed? □ Right □ Left Can you please describe the nature of your problems? ______________________________________________________________________________________________________________________________________________________________________________________ Have you had a prior problem with this same Orthopaedic condition in the past? (explain below if yes) _______________________________________________________________________________________________ How long has this problem been present? ____________________________________________________ Check the ONE box which best fits how your problem started. (Use as much space to the right as needed.) □ NO INJURY (for example, arthritis pain) (Onset was: □ Gradual or □ Sudden) Why do you think it started? ____________________________________________________________ □ AUTO ACCIDENT Date_________ Where and How did it Happen? ________________________________________________________ □ WORK RELATED Date_________ Where and How did it Happen? ________________________________________________________ □ INJURY (other than an auto accident or work injury) Date_________ Where and How did it Happen? ________________________________________________________ The pain or problem is: □ Constant □ Comes and goes (Intermittent)
Severity of pain □ None □Mild □Moderate □Severe □Extremely severe □ Incapacitating/ worst pain in your life
Patient Printed Name: __________________________________________________________ Page 1 of 3
What is the Quality of the pain? □ Sharp □ Dull □ Stabbing □ Throbbing □ Aching □ Burning □ Other: _______________ Are there associated symptoms? □ Swelling □Numbness □ Weakness □ Redness □ Other: ______________ Since your problem started, is it: □ Getting Better □ Getting Worse □ Unchanged What makes your symptoms worse? □ Activity □ Exercise □ Work □ Other: _________________________ Does anything make you feel better? □ Rest □ Heat Ice □ Elevation □ Other: _______________________ Have you tried any of the following for this problem? □ Brace □ Cane □ Crutches □ Walker □ Orthotics / prescription shoes □ Medications / Other _______________________________________________________________________ Have you tried physical therapy for this problem? If so,how recently? ______________________________
Have you ever had any steroid (cortisone) injections for this problem? If so, how recently?
Have you ever had any Synvisc, Hyalgan, Supartz, or Euflexxa injections for this problem?
If so, how recently? ____________________________________________________________________
ARE YOU A DIABETIC? □ Yes □ No
IF DIABETIC, CURRENT TREATMENT: □ lnsulin □ Oral Medications □ Diet □ None
Do you have sleep apnea? □ Yes □ No
ARE YOU ALLERGIC TO ANY MEDICATIONS? If so, what happens? _______________________ (Please check any that apply, or mark None)
□Weight loss □Loss of appetite □Fever □Cancer
□Glasses □Contacts □Double Vision □Cataract □Blindness □
□Hearing Loss □Hoarseness □Ringing in Ears
□High blood pressure □Heart condition □Blood clots
□Asthma □Cough □Short of Breath □Tuberculosis
□Stomach ulcer □Hepatitis □Blood in Stool
□Pain with Urination □Blood in Urine □Kidney disease □
□Skin Ulcers □Rash □Lumps □Blisters
□Seizures □Stroke □Balance Problem □Headaches
□Depression □Sleep disorder □Other psychiatric illness
□Easy bleeding □Easy bruising □Anemia □Other (describe) □
HAVE YOU TAKEN ANY OF THE FOLLOWING FOR THIS PROBLEM: (Circle all that apply)
Advil Ibuprofen/Motrin Lodine Naprosyn Tylenol Ultram/tramadol Celebrex Mobic Aspirin
How long have you taken them? ________________________________________________________________________________
Patient Printed Name:
WHAT OTHER MEDICATIONS DO YOU TAKE? (If you have a separate list, we can copy it.)
***Please make sure to include any vitamins, supplements or over the counter medications ***
DO YOU EAT A SPECIAL DIET? □ Yes □No Describe:_______________________________________
PAST SURGICAL HISTORY: What operations have you had and in what years? □None
Have you ever had a reaction to anesthesia? □ Yes □No
If yes, please elaborate: ______________________________________________________________
Have you ever had a blood transfusion? □ Yes □No
Did you have any problems with it? ___________________________________________________
FAMILY HISTORY: Have any direct relatives had any of the following disorders?
□ Diabetes □ High Blood Pressure □ Heart disease □ Arthritis □ Cancer
Any direct relative with the same Orthopaedic condition
you are being seen for today?
If direct blood relatives are deceased, can you please describe the cause of death (e.g., mother, father,
Do you currently use tobacco?
□ Used to smoke, but stopped _______ years ago.
□ None □ Yes: How often? ___________________________________
:_________________________Employer:______________________________________________ If Student,
School:________________________________________________ Grade:____________________ Are you currently working?
□Yes □ No : If no
, how long have you been off work?_________________
If working, can you please describe what’s involved? (e.g., heavy lifting, desk work, etc.):
FOR WORKMAN’S COMPENSATION CASES ONLY: WC CLAIM #:__________________________
Date of injury: ____________ First date of disability: __________ Last date worked:_____________
If out of work now, who has taken you out of work? ________________________________________
Do you have any current or pending litigation involving this problem for which we are seeing you today? □Yes □No
If so, should we expect requests for information from any parties involved? _______________________________________________
* Everything I have answered is true and correct to the best of my knowledge. I understand that this is a confidential record of
my medical history and will be kept in my chart. Information contained here will not be released without my authorization to do
Patient Signature: ____________________________________ Date: ______________________ Patient Printed Name:
___________________________________________________ Page 3 of 3
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Campus Security and Safety Report Prairie du Chien, Wisconsin Center This information is being provided to all students and employees as part of Upper Iowa University’s commitment to safety and security at the Prairie du Chien Center and in compliance with the Federal Student Right-to-Know and Campus Security Act (1990), Public Law 101-542, as amended by the Higher Education Technical