First Name
E-Mail
ORTHOPEDIC MEDICAL HISTORY QUESTIONNAIRE
Address
Last Name
City
State
Zip
Country
Phone # (if none, put none)
Date of Birth
Procedures Requested
Height
Gender
Weight
Do you smoke?
Current medications and supplements
Please Check all that Apply:
Addiction to alcohol or drugs
Arthritis
Asthma/Breathing Problems
Autoimmune
Bleeding Problems / Blood Clots
Blood Disorders
Cancer
Cardiac Arrhythmia (rapid heart rate)
Chronic Pancreatitis
Cirrhosis of the Liver
Exposure to Tuberculosis
Gallstones
Heart Murmur
Hepatitis
Heart or Vascular disease
High Blood Pressure, Coronary Artery Disease or Circulatory conditions
HIV or AIDS
Hypertension/ High Blood Pressure
Kidney Disease
Metabolic Conditions. (i.e. hypothyroidism)
Seizures or Epilepsy
Sleep Apnea
Stroke
Thromboembolism
Type 2 Diabetes
Do you have any medical condition that you have been told would disqualify you for any type of medical procedure or surgery?
Do you have special needs that need accommodation? (dietary, sensory, handicap, etc)
Do you have any other medical condition that you are aware of that is not listed above?
If you checked or said yes to any above, please explain
Your Medical Provider
Provider Contact #
Do we have permission to contact?
Please list all previous surgeries or hospitalizations
Please list all allergies
How did you hear about us?
Chronic, Long term Steriods (past or present)
Have you ever had a fracture or
a broken bone?
Do you have a prothesis?
Hernia
Do you use a walking device?
Please describe your current symptoms and level of pain/weakness/tingling/numbness with corresponding normal activities?
How long have you had the pain?
What have you done to try to
alleviate your condition and
what were the results?
Do you have current XRAYS?
Is this condition related to
an accident/trauma, arthritis or
a genetic condition? Please explain.
Do you have a current MRI?
Previous reactions to Anesthesia
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