This information is CONFIDENTIAL and will become part of your

This information is CONFIDENTIAL and will become part of your

MEDICAL HISTORY FORM
PLEASE TAKE ENOUGH TIME TO FILL OUT THIS QUESTIONERE TO THE BEST OF YOUR ABILITY. ANSWER ALL OF THE QUESTIONS. THIS WILL ALLOW THE PHYSICIAN TO MAKE A DIAGNOSIS MORE ACCURATELY AND BETTER PLAN FOR YOUR CARE. This information is CONFIDENTIAL and will become part of your permanent medical record. DATE: ____/____/____ Fecha: NAME: _______________________________________________ Nombre: OCCUPATION: ________________________________________ Ocupacion: SEX: _____ AGE: _____ HEIGHT: ____ft. _____in. WEIGHT: _____ lbs Sexo: Edad Altura Peso Single? ___; Married? ___; If yes, how long? ___ Divorced? ___; Widowed? ___ Soltero Casado Cuanto tiempo? Divorciado Viudo If you have any children, how many girls? _____ , Boys? _____ Si Tiene hijos, Cuantos Ninas Ninos Referring Physician:________________________________ Phone: _________________________ Doctor que lo refirio? # Telefono: Address:____________________________________________________________________________ Direcion: Primary Care Doctor:________________________________ Phone:_________________________ Medico Primario: Address:_____________________________________________________________________________ Pharmacy Name:_____________________________________ Phone:_________________________ Farmacia: Address: ____________________________________________________________________________
Initials (inciales)______
HISTORY: Why are you seeing the Doctor today? __________________________________________________________ Cual es la razon de su visita? _________________________________________________________________________________________ When did your problem begin? Approximate Date ___/ ___/ ___ Cuando comienzo su problema? Aproximadament?. How did your problem begin? ________________________________________________________________ Como empezo su problema? _________________________________________________________________________________________ TODAY, where is your pain? _________________________________________________________________
Hoy, donde es su dolor? _________________________________________________________________________________________ MARK YOUR PAIN ESTIMATE Haga una escala de su dolor No Pain 0 ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐10 intolerable pain (No dolor) 25% 50% 75% (dolor insoportable) What medicines are you taking for your pain? ____________________________________________________ Que medicinas esta tomando para su dolor? _________________________________________________________________________________________ Have you had any of the following treatments for your pain? If yes, When, How long and did the treatment help or worsen your condition? Ha tenido alguna vez alguna de los siguientes tratamientos para el dolor? Si la repuesta es afirmative por cuanto tiempo y se mejoro o empeoro su condicion? Physical Therapy: _________________________________ Terapia Fisca: Chiropractic: _________________________________ Quiropractico Injections: _________________________________ Inyecciones: Initial (inciales)_________ ONLY ANSWER QUESTIONS WHICH APPLY TO YOUR PROBLEM Solo reponda las preguntas que apliquen a su problema If you have NECK PAIN does it RADIATE into: your shoulders, ________ ( R / L / Both), Si tiene dolor de cuello, el dolor le va a los: Hombros (D/I/ ambos
your arms? _____ ( R / L / Both), your hands? _____ ( R / L / Both). Sus brazos? Sus manos? Do you have NUMBNESS in your arms? _____ ( R / L / Both), your hands? _____ ( R / L / Both) Tiene adormecimiento en sus: brazos? Sus manos? If you have BACK PAIN does it RADIATE into: your buttocks? _____( R / L / Both), Si tiene dolor de espalda, el dolor va a gluteos? your legs? _____ ( R / L / Both), your feet? _____ ( R / L / Both) Sus piernas? Sus pies? Do you have NUMBNESS in: your legs? _____ ( R / L / Both), your feet? _____ ( R / L / Both) Tiene adormecimiento en sus……...piernas? Sus pies? What makes the pain WORSE? Sitting? _____, Prolonged Standing? _____, Walking? _____, Que hace empeorar el dolor? Sentado? Mucho parado? Caminar? Bending? _____, Lifting? _____, coughing or sneezing? _____, Anything else? ______________________ Doblarse? Levantar algo? Toser or estornuado? Otro? What DECREASES the pain? Sitting? _____, Sitting in a recliner? _____. Walking? _____ Que desminuye el dolor? Sentarse? Sentarse reclinado? Caminar? Stretching? _____ Holding your arm over your head? _____Lying down? _____ Estrecharse? Sostener el brazo sobre la cabeza? Recostarse? Or any other method? ____________________________________________________________________ O otro metido? Do you wear a corset or brace for your pain? _____________________ (yes / no) Usa corset o sostnedor para el dolor? Have you had any change in your bowel or bladder function since your problem began? If so please Described these changes? _________________________________________________________________ Ha notado algun cambio cunado orina o evacua , por favor describe los cambios? Have you ever been hospitalized for back, neck or leg pain? _____ If yes, please list when and for how Long? ________________________________________________________________________________ Alguna vez ha estado hospitalizado por dolor en la espalda, el cuello o dolor en las piernas? Initial (inciales)_________ If you have HIP _____ (R / L) or KNEE _____ (R / L) pain: Tiene dolor en la cadera? Rodilla? Dose the pain wake you up at night? _____ Can you walk up stairs foot over foot? ______ El dolor lo despierta por las noche? Puede usted subir escaleras? How long can you stand? __________________________ Cuanto tiempo puede estar parado? How far can you walk? __________________________ Que tan lejos puede cominar? Do you limp? _____ Esta cojea? Does your knee swell? ______ or give out? ______ Se le hinchon las rodillas? Se debilitan las rodillas? Can you get up from a chair without difficulty? _____ Se puede usted levanter de una silla sin dificultad? Can you cut your toenails? _____ Puede usted cortarse las unas de los pies? Can you tie your shoes? _____ Puede usted amrrarse los zapatos? Do you use a cane? _____ or walker? _____ Usa usted un baston? Un andador? If you have SHOULDER _____ (R / L) pain: Si tiene dolor de hombros______ Does the pain wake you up at night? _____ El dolor lo despierta de noche? Is it aggravated by: El dolor empeora si: Using your arms overhead? _____ Sube los brazos por encima de la cabeza? Twisting you neck? _____ Dobla el cuello? Lifting object? _____ Levanta objectos? Other? ______________________ Otro? Have you ever dislocated your should? If so, how many times? _____ Alguna vez se has dislocado un hombro? Si la repuesta es si cuantas veces? Initial (inciales)_________ HAVE YOU HAD ANY OF THE FOLLOWING TESTS? Se ha hecho alguna vez algun de los siguientes estudios? X‐ray: ____________________________ (back, neck, etc.) Placas? Myelogram: ____________________________ Myelograma: Cat Scan: ____________________________ Bone Scan: ____________________________ Estudio de los huesos? EMG: ____________________________ Estudio de los nervios o musculos? SSEP: ____________________________ MRI: ____________________________ Estudio de Resonancia magnetica? Were you injured in an automobile accident? _____ Se ha lastimado en un accidente auto movilistico? Were you the driver? _____ Was your seatbelt on? _____ Era usted el conductor? Tenia su cinturon de seguridad puesto?
Have you retained an attorney? _____ If so please give his name and address in case we need to be in Communication with him/her. Tiene Abogado? En caso affirmative, favor dar su nombre y direccion en case de que necesitemos ponernos en contacto con ellos ____________________________Esq. ____________________________ ____________________________ ____________________________ PAST MEDICAL HISTORY: SU HISTORIA MEDICO: List ALL surgeries that you have had utilizing anesthesia? _______________________________________ Alguna cirugia en la cual usted ha usado anestesia? ______________________________________________________________________________________ Do you have ALLERGIES to medications? _____ Please list them. _______________________________ Alguna alergia a medicamentos? Si, Por favor indicar ______________________________________________________________________________________ List ALL the medications you are taking now. Escriba todos los medicamentos que este tomando en la actualidad ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ Initial (inciales)_________
Have you had any prolonged fever or chills in the past few months? _____ ( Yes / No) If so please He tenido usted fiebre or escalofrios por largo tiempo en los ultimos meses? Describe. _______________________________________________________________________________ Have you lost a significant amount of weight in the past six months? _____ If Yes, How much? _____lbs. He perdido peso de manera significante en los ultimos 6 meses? Si es Si, Cuanto? Do you SMOKE? _____ How many packs a day? _____ Usted fuma? Cuanto al dia? Do you drink alcohol? _____ If so, how many drinks per day? _____ per week? _____ Usted toma alcohol? Si es si, cuanto por dia? Por semana? Do you use antacids? _____ If Yes, please list. _________________________________________________ Usted usa antiacidos? REVIEW OF SYSTEMS: Have you ever had any of the following? Answer Yes or No. Ha tenido algunos de los siguientes problemas? High Blood Pressure _____ Tuberculosis _____ Presion Alta Tuberculosis
Diabetes _____ Hepatitis _____ Diabetis Hepatitis Asthma _____ Epilepsy _____ Asma Epilepsia
Heart Attack _____ Depression _____ Ataque de Corazon Depresion Angina _____ Stomach Ulcers _____ Angina de pecho Ulceras Heart failure _____ Cancer _____ Enfermedad del Corazon Cancer Kidney Problems _____ HIV _____ Enfermedad del Rinon HIV
Liver Problems _____ Easy Bruising _____ Enfermedad del higado Moratones en la piel Emotional Problems _____ Drug Problems _____ Problemas emocionales Problemas de drogas
Drinking Problems _____ Other _____ Problemas con el alcohol Otro
Have you had a rectal examination in the past year? _____ Ha tenido un examen rectal en el ultimo ano? When was your last PAP smear (woman only)? ___ / ___ / ___ Cuando fue su ultimo papanicola Initial (inciales)_________ FAMILY HISTORY: Are you parents alive? _____ If not, what was the cause of death? Sus padres estan vivos? Si no, cual fue la causa de al muerte? Mother? _____ ( alive / dead); present age or age at death? _____. Any serious chronic condictions/cause of Madre? (viva/muerta). Edad actual or que edad murio? Alguna enfermedad sera or cronicas causa
death? ____________________________________________________________________________________ de muerte? Father? _____ ( alive / dead); present age or age at death? _____. Any serious chronic condictions/cause of Padre? (vivo/ muerto) Edad actual, o que edad murio? Alguna enfermedad sera or cronicas causa death? ____________________________________________________________________________________ de la muerte? Since we cannot see your pain this allows us to see where you are feeling the pain. Mark the areas on your body where you feel the described sensations. Use the appropriate symbol or use a symbol of your choosing, and including ALLof the affected areas. Ya que no podemos ver su dolor, esto no ayudara a ver donde es que usted siente su dolor. Marque las areas del cuerpo donde usted siente molestias o sensaciones abnormales. Use los symbolos apropiado or symbolos que usted desea en las areas afectado se su cuerpo. +++ 0000 ==== xxxx //// ++++ 0000 ==== xxxx //// ++++ 0000 ==== xxxx //// ACHE NUMBNESS PINS+NEEDLES BURNING STABBING Adolorido Adormecimiento Hormigueo Ardor Pulsante Initial (Iniciales) ________________