Medical History Information Name: _______________________________________ Date of Birth: _______________________

What are we seeing you for today?______________________________________________

Pain Scale: On a scale from 0-10 what is your pain level?____________

Allergies: □ NONE

List any allergies (medication or other allergies) Drugs/Latex/Food/Contrast/Other Severity and Reaction 1. 2. 3.

Social History:

Tobacco: □ Never □ Current (Amount: _____ Pack/Day for _____ years) □ Former (Age start: _____ Age stop: ______)

Alcohol: □ Never □ Current (Amount: _____/week for _____ years) □ Former (Age start: _____ Age stop: ______)

Illicit Drugs: □ Never □ Current □ Former Marijuana: □ Never □ Current □ Former

Medical Problem History: □ NONE

List any chronic medical conditions you are being treated for with approximate date(s) you were diagnosed. (Ex: Anxiety, diabetes, high blood pressure, etc.) Condition Date of Onset Condition Date of Onset 1. 4. 2. 5. 3. 6.

Past Surgical History: □ NONE

List any significant surgeries with approximate date(s) of procedure(s). Type of Surgery Date Type of Surgery Date 1. 4. 2. 5. 3. 6.

Family Medical History: □ NONE

List any significant medical history that runs in the family with approximate date of onset. Condition Relationship Maternal or Paternal Age Onset 1. 2.

Medications: □ NONE

List any prescribed medications, vitamins, and/or over-the-counter medications taken on a daily basis. Include dosage information (mcg, mg, etc) and frequency taken (once daily, twice daily, etc). Prescribed Medications Dose & Frequency Vitamins/OTC Dose & Frequency 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. 8. 8.