Patient History
Patient Information
Patient name
*
Date of birth
*
Height
*
Weight
*
Primary care physician
*
Are you pregnant?
*
Yes
No
Latex Allergy?
*
Yes
No
Employer
*
Job Duties
*
Pharmacy name
*
Address
*
Phone
*
Chief Complaint
Which body part?
*
Which side?
*
Right
Left
Both
Injury date/symptom onset
*
Was this an injury?
*
Yes
No
Was this an auto accident?
*
Yes
No
Was this a work injury?
*
Yes
No
Was it reported?
*
Yes
No
How did the injury happen?
*
Rate your pain level for this problem today
*
0
1
2
3
4
5
6
7
8
9
10
No
pain
Moderate
pain
Worst
possible
pain
Habits
Smoking
*
Current every day
Current some day
Current-unknown
Former
Never
Unknown
What type?
Cigarettes
Cigars
Pipe
Vape
Cannabis
Alcohol
*
Yes
No
How much?
*
How often?
*
Caffeine
*
Yes
No
How much?
*
How often?
*
Recreational Drugs
*
Yes
No
What type?
*
How often?
*
Exercise
*
Yes
No
What type?
*
How often?
*
Medication Information
Do you have any medication allergies?
*
Yes
No
Medication Allergies
*
Add another?
Are you currently taking any medications?
*
Yes
No
Medication List
*
Add another?
Add another?
Add another?
Add another?
Add another?
Additional medication information
Hospitalizations, surgeries or major illnesses
Review of Systems
Please indicate whether you have been diagnosed with any of the following conditions:
*
HIV-AIDS
Hepatitis/Liver disease
Cancer/Malignancy
Thyroidism (hyper or hypo)
Diabetes
Heart Disease
Angina/Heart Attack/Chest pain
High Blood Pressure
Low Blood Pressure
Bursitis
Emphysema/COPD
Kidney Disease
Frequent Infections
Polio
Phlebitis
Anemia
Migraines
Paralysis
Stomach Ulcers
Recurrent Stomach Pain
Neuritis/Neuralgia
Pain-Stiffness in Neck/Back
Asthma
Weakness of Hands or Feet
Tingling of Hands or Feet
Meningitis
Swelling/Pain in Joints
Muscle Spasms
Unconscious Spells
Sinus Problems
Concussions or Head Injury
Trembling of Hands
Psychiatric Condition
Alcoholism/Drug Addiction
Stroke
Sciatica
Rash
Weight Loss/Gain
Other
I have never had any of these conditions diagnosed
I, the undersigned, agree that Kansas City Orthopedic Alliance may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payors for treatment purposes.
Signature of Patient/Parent/Guardian
*
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Date
*