PATIENT HISTORY
Dr. Kent R. Walker, D.O.
Specializing in Family Practice (Replace With
Your Logo)
And Sports Medicine
Patient Name________________________________________
Date___________
Date
of Birth__________________ Sex__________
Marital Status____________
Telephone
Numbers/Home ( )______________
Work ( )________________
Home Address_____________________________________________________
Street_____________________________________________________________
City____________________
State__________ ZIP____________
General
Health
Review
Medical History (such as heart disease, stroke,
cancer, arthritis, diabetes, hypertension, as well as
Psychiatric illnesses, etc.)
__________ ___________
___________
__________ ___________
___________
Surgical History (unrelated
to pain; such as appendectomy)
__________ ___________
___________
__________ ___________
___________
Surgical History (related
to pain; such as laminectomy)
__________ ___________
___________
__________ ___________
___________
Allergies (include medication and food allergies)
__________ ___________
___________
__________ ___________
___________
Intolerances (include side effects from previous
medications, such as gastritis, nausea, constipation, etc.)
__________ ___________
___________
__________ ___________
___________
Current Medications (include vitamins and birth
control pills, if applicable)
__________ ___________
___________
__________ ___________
___________
Do you have any of the following? (Circle all that
apply)
Headaches
Stomach Pain
Chest Pain
Vision Problems
Nausea
Shortness of Breath
Hearing Problems
Vomiting
Urinary Problems
Dizziness
Constipation
Rashes
Difficulty Swallowing
Diarrhea
Swollen Joints
Chronic Fatigue
Domestic
Situation
With whom do you live?______________________________________________
Are there any substance abuse issues in the
household?
Yes_____ No_____
If yes, please explain_______________________________________________________
Are you able to take care of yourself?
Yes_____ No_____
If not, please enter name of caregiver__________________________________________
Work History
Job
Years worked
Why did you leave?
______________________________________________________________________________________
Legal Matters
Are
you presently involved in a lawsuit?
Yes_____ No_____ If yes, please explain.
_______________________________________________________________________________________
_______________________________________________________________________________________
Substance Use
Which
of the following drugs or substances, if any, have you used in the past?
(Circle all that apply)
Next to each drug or substance that you’ve circled, indicate if you
used it occasionally (“O”), frequently
(“F”), or continuously (“C”).
Alcohol
Barbiturates
Cocaine
Heroin
Amphetamines
Marijuana
Other (specify)
Other
Other
Are
you presently using any of the drugs or substances below? (Circle all
that apply)
Next to each drug or substance that you’ve
circled, indicate if you use it occasionally (“O”), frequently
(“F”),
or continuously (“C”).
Alcohol
Barbiturates
Cocaine
Heroin
Amphetamines
Marijuana
Other (specify)
Other
Other
Do you presently smoke cigarettes or use tobacco in
any form?
Yes_____
No_____
If not, did you ever smoke cigarettes or use
tobacco in any form?
Yes_____
No_____
How many packs do (did) you smoke a day? _____
For how many years? _____
May be duplicated for use in clinical practice.
© 1996 Purdue Pharma L.P. 8/99
A6183-PH MC144B
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