Illinois Bone and Joint Institute, LLC
MEDICAL HISTORY FORM

PATIENT INFORMATION


Today's Date

Last Name First Name Middle Intial
Email Address:
Age:    Sex: M F
Date of Birth    
Height:    Weight: lbs    BP    Temp

HISTORY OF PRESENT ILLNESS
Reason for today's visit:
Date of injury or onset: / /
How did the pain begin?
Problem due to: car accident work related sports injury fall arthritis
other
If injured, where did injury occur? home work school N/A
other
Are you off work due to injury? no yes If yes, last day worked
If an injury, is there litigation pending? no yes
Location of pain:
If the problem is related to a limb is it: right left both

Indicate the characteristics that describe your problem:
Pain
sharp
dull
throbbing
aching
burning
cramping
other
Onset
sudden
slowly
Severity
minor
moderate
severe		 Frequency
intermittent
constant
Timing
am or pm
while sleeping
after activity
during activity		 Context
standing
kneeling
down stairs
walking
coughing
sitting
lying down
up stairs
running
lifting a heavy object
straining with a
bowel movement

Associated Symptoms:
instability
chills
sensitive to touch
vomiting
visible swelling 		weakness
grinding
sensitive to temperature
rash
bruising		 stiffness
popping
limb deformation
visual changes
numbness		 changes in bowel
or bladder function
locking
temperature change
tingling
others
fever
giving way
nausea
Does the pain move? no yes Where to?
How often do you have the pain? constantly hourly daily weekly
What makes it better? rest heat cold elevation physical therapy braces
injections medications other
What makes the pain worse?
Is this the first time you have had problem with this area? no yes
Describe prior problem:

For this problem have you had any of these tests: X-Ray MRI CT scan ultrasound
bone scan EMG nerve study If so, where?

Did you bring them with you? yes no

Prior Treatment:
oral medication medicines:

injection how many:

chiropractor		 braces type:

physical therapy for how long:

where 		heat
cold
elevation
cane crutch walker wheelchair other
Previous Treating Physician:
Has a physician recommended that you have surgery for this problem? yes no

Past Medical History: Have you or any family member had any of the following medical problems?
You Family You Family














kidney stones
endocrine disorders
diabetes
asthma
emphysema
tuberculosis
ulcers
colitis
reflux
stroke
nervous disorder
depression
HIV/AIDS
hepatitis
lyme disease















cancer
anemia
bleeding disorder
blood clots /pulmonary embolism
phlebitis
atrial fibrillation/or Irregular heartbeat
heart trouble/disease
high blood pressure
high cholesterol
arthritis
rheumatoid
osteoarthritis
osteopenia
osteoporosis
balance problem
sleep apnea
none of the above others

Family Medical History: If your parents, grandparents, siblings, or children have any of the medical
problems listed above, please explain:
Are you pregnant? yes no       Breast feeding? yes no
Have you (or are you) receiving all the standard child immunizations? yes no
If no, please explain:
Have you ever received a tetanus shot? no yes
If yes, please provide approximate date of last tetanus shot: / /
Have you had a prior blood transfusion? no yes If yes, when?
Have you ever had problems with anesthesia? no yes
If yes, what problems?

Past Surgical History:
Type of surgery: year
Type of surgery: year
Type of surgery: year
Type of surgery: year
Type of surgery: year
Type of surgery: year

Prescription / Nonprescription Medications: (including herbal supplements and vitamins)
Name: Dose: Taken per day:
Name: Dose: Taken per day:
Name: Dose: Taken per day:
Name: Dose: Taken per day:
Name: Dose: Taken per day:
Name: Dose: Taken per day:
Name: Dose: Taken per day:
Name: Dose: Taken per day:

Allergies:
none
penicillin/antibiotics
sulfa		 codeine/pain medications
iodine
contrast		 shellfish
local anesthetics
lidocaine		 Novocain
latex
 metal/jewelry
aspirin
food others
Type of reaction:

Social History:
Occupation Working now? yes no retired disabled
Do you use tobacco? no yes       If yes, packs per day:
                                    Pipe? yes no       Smokeless? yes no
                                     quit       if quit, years smoked:

Alcohol use: never occasional daily heavy
History of alcoholism? yes no History of drug use? yes no
 
Marital status: single married divorced widowed
Do you live alone? yes no       If no, who do you live with?
Type(s) of exercise/sports activity:       How often? per week

Review of Systems: are you currently having problems with any of the following:

Genitourinary
blood in urine
kidney stones
Frequency
sexual problems
retention
testicle pain
menstrual problems
foul odor/cloudiness

Skin
rash/itching/psoriasis
breast lump
hair change
nail change

Eyes
wear glasses/contacts
blurred vision
eye disease
glaucoma

Constitutional
weight change
fever
chills
fatigue

Gastrointestinal
nausea/vomit
stomach pain
rectal bleeding
bowel problem/colitis

Musculoskeletal
pain/cramps
joint swelling
joint pain
trouble walking

Endocrine
excessive urination
thyroid disease
hormone problem

Respiratory
short of breath
cough
wheezing
bronchitis

Hematologic
bruise easily
slow to heal
enlarged glands

Neurological
headaches
tremors
seizures
numbness
weakness

Ears/Nose/Mouth/Throat
hearing loss/ringing
sinus problems
nose bleeds
sore throat

Cardiovascular
chest pain
palpitations
heart trouble
swelling

Psychiatric
insomnia
confusion
depression

Patient/Guardian Statement:

To the best of my knowledge, the above information is accurate and complete.

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Medical Professional Signature Date

Provider Statement:

I have reviewed the questionnaire with the patient.

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