Orthopaedic Surgical Associates, LLC

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Medical History Form

Please fill out this form completely. The following information will help us in providing you the best medical care and treatment possible. If you have any questions, please contact the office. Thank you and we look forward to seeing you!

Patient Information

First Name *

Last Name *

Preferred Name/Nickname

Date of Birth *

Sex *

Gender

Additional Information

Who is your Primary Care Provider (PCP)? *

Are there any other doctors that you see on a regular basis?

Height *

Weight *

Occupation *

Dominant Hand *

Please briefly describe your current injury/illness: *

Medical History

Please list all medications you are currently taking (including over the counter and vitamins/supplements) *

Please list any allergies *

Please check all that apply *

Type of Cancer

(If Applicable)

Other

(If Applicable)

Social History

Occupation *

Do you smoke? *

How many cigarettes per day?

(If Applicable)

Any other forms of tobacco?

List

(If Applicable)

Do you drink alcohol?

How often?

(If Applicable)

Do you use any illicit drugs?

List

(If Applicable)

Family History

Does anyone in your family (living or deceased) have the following:

Please check all that apply

High Blood Pressure

High Cholesterol

Cancer

Stroke

Heart Disease

Diabetes

Depression

Mental Illness

Hypothyroidism

Other

Surgical History

Please select/list all surgeries:

Please check all that apply:

Appendix

Tonsils/Adenoids

Hysterectomy

Gallbladder

C-Sections

Heart

Other

Functional History

Do you need help with any of the following:

Equipment Used for Walking :

Cane

Wheelchair

Walker

N/A

* Required field