Patient Name: ___________________ Date of birth: / / Patient Intake Information GENERAL MEDICAL HISTORY/FAMILY HISTORY (P=Patient, F=Family Member) Please check if you or your family has a history of: P F P F P F Alcoholism Depression Joint Pain Allergies/Hayfever Diabetes --on insulin Kidney Infections Anemia Diabetes-- not on insulin Kidney stone Anxiety Epilepsy or seizures Migraine Asthma Fracture Multiple Sclerosis Irregular Heart Rhythm Stomach ulcer Obesity Blood Transfusions Gastrointestinal Disease Heart Attack Blocked blood vessels GERD/Reflux Arthritis Gestational (pregnancy) Cancer Osteoporosis Diabetes Heart Disease Glaucoma Pneumonia Congestive Heart Failure Heart Murmur Lung Disease Cirrhosis or liver disease Hepatitis Rheumatic Fever Colitis High Cholesterol Rheumatoid Arthritis COPD or emphysema Hyperlipidemia Sexually Transmitted Disease Chronic kidney High Blood Pressure Thyroid Disease disease/dialysis Crohn’s Disease Hyperthyroidism Suicide Attempt Stroke Hypothyroidism Tuberculosis OTHER MEDICAL HISTORY HOSPITALIZATIONS MEDICATIONS DRUG ALLERGIES REACTION: TOBACCO ASSESSMENT How many packs per day? Do you smoke? Yes No Have you ever smoked? Yes No Date you quit: _________ How many years? Have you ever tried to stop? Yes No SOCIAL HISTORY Complete the following: If Yes: Complete the following: Do you use Alcohol? No Yes __drinks per __ Educational Level No Yes __ drinks per __ Single Married Separated Do you use caffeine? Marital Status (circle) Divorced Widowed Drug Use at any time? No Yes Exercise Habits Describe: IV Drug Use at any time? No Yes Do you always wear Seatbelts? No Yes Describe: Do you use sun protection No Yes No Yes Do you have Body piercings? (sunscreen)? Do you have Tattoos? No Yes Birth Control Methods Are you Sexually active? No Yes Language spoken Occupation Religion
Patient Name: ___________________ Date of birth: / / Patient Intake Information GENERAL MEDICAL HISTORY/FAMILY HISTORY (P=Patient, F=Family Member) Please check if you or your family has a history of: P F P F P F Alcoholism Depression Joint Pain Allergies/Hayfever Diabetes --on insulin Kidney Infections Anemia Diabetes-- not on insulin Kidney stone Anxiety Epilepsy or seizures Migraine Asthma Fracture Multiple Sclerosis Irregular Heart Rhythm Stomach ulcer Obesity Blood Transfusions Gastrointestinal Disease Heart Attack Blocked blood vessels GERD/Reflux Arthritis Cancer Gestational (pregnancy) Diabetes Osteoporosis Heart Disease Glaucoma Pneumonia Congestive Heart Failure Heart Murmur Lung Disease Cirrhosis or liver disease Hepatitis Rheumatic Fever Colitis High Cholesterol Rheumatoid Arthritis COPD or emphysema Hyperlipidemia Sexually Transmitted Disease Chronic kidney disease/dialysis High Blood Pressure Thyroid Disease Crohn’s Disease Hyperthyroidism Suicide Attempt Stroke Hypothyroidism Tuberculosis OTHER MEDICAL HISTORY HOSPITALIZATIONS MEDICATIONS DRUG ALLERGIES REACTION: TOBACCO ASSESSMENT Do you smoke? Have you ever smoked? Date you quit: _________ Have you ever tried to stop? Yes No Yes No Yes No How many packs per day? How many years? SOCIAL HISTORY Complete the following: If Yes: Complete the following: Do you use Alcohol? No Yes __drinks per __ Educational Level Do you use caffeine? No Yes __ drinks per __ Marital Status (circle) Single Married Separated Divorced Widowed Drug Use at any time? No Yes Describe: Exercise Habits IV Drug Use at any time? No Yes Describe: Do you always wear Seatbelts? No Yes Do you use sun protection (sunscreen)? No Yes Do you have Body piercings? No Yes Do you have Tattoos? No Yes Birth Control Methods Are you Sexually active? No Yes Language spoken Religion Occupation
Patient-Intake-Form-Sports-med-form.docx