Microsoft word - tjc patient intake form-1-

Total Joint Care
PERSO AL HEALTH QUESTIO
Please take a few moments to provide the following important information about your current health
and clinical history. It will help us provide you with the best possible care. We appreciate it!

ame:_______________________________ Primary Care Doctor: ____________________________

Referred by: PCP Friend Self Other: _______________
Reason for visit today:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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Past Medical History
Medications/Vitamins/Herbal Supplements
(please check each box that applies)
(if have list, give to front desk. Don’t need to fill out.)
1. _____________________________________ 2. _____________________________________ 3. _____________________________________ 4. _____________________________________ 5. _____________________________________ 6. _____________________________________ 7. _____________________________________ 8. _____________________________________ 9. _____________________________________ 10. ____________________________________ 11. ____________________________________ 12. ____________________________________ Renal failure/dialysis Liver disease/hepatitis Medication Allergies O E K OW
Other: ____________ Other: _______________ Other: ____________ Other: _______________ Infection (type): _________________ Other: _________________ Other: _________________ Other: _________________
Previous Hospitalizations, Surgeries
1. ________________________________________________
_____________________
2. ________________________________________________
_____________________
3. ________________________________________________
_____________________
4. ________________________________________________
_____________________
5. ________________________________________________
_____________________

Social History
Marital Status: Single Married Divorced Separated Widow
Occupation: _________________________________ Retired
Do you smoke? Yes No
Chew tobacco? Yes No Use recreational drugs? Yes No Do you drink alcoholic beverages? Socially Never Daily Family History
(Please check any that apply and indicate by (number), family member(s) with same medical history)
Mother(1) Father(2) Mother’s Parents(3) Father’s Parents(4) Siblings(5) Children(6)

Do you or have you had any infectious diseases? one
Skin / Abdominal / Other (When?) ______________________________________
Review of Symptoms: (Please check all that apply)
General:
Excessive fatigue Weakness Fever Other: _______
Eye Problems:
Glasses Cataracts Glaucoma Other: ____________
Ear, ose, Throat:
Poor swallowing Nose bleeds Sore throat Ear pain Hearing loss Other: _____________________
Cardiovascular:
High blood pressure Chest pain Palpitations Blood clot Heart attack Vascular problems Other: _______________
Respiratory:

Gastrointestinal:
Heartburn Nausea Abdominal pain Reflux/Ulcers Constipation Gallbladder problems Other:____________
Genitourinary:
Frequent UTIs Blood in urine Other: ________________
Musculoskeletal:

Integumentary:
eurological/
Psychological

Endocrine:
Weight gain Weight loss Diabetes Thyroid Disease Gout Liver problems Other: _____________________
Hematologic:
Bruise easy Prolonged bleeding Anemia Other:______
Reproductive:
Pelvic pain Heavy bleeding Cyst Other: __________ If female, are you pregnant? Yes No Date of last period:____
Please describe significant symptoms, medical problems or personal events not marked above:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Thank you for taking the time to provide this important information!

Patient Signature: _____________________________________________
Date: ____________
Legal Guardian or POA Signature: ______________________________
Date: ____________

I have personally reviewed, confirmed or modified as necessary the above information
Physician Signature: ___________________________________________
Date: ____________

Source: http://www.totaljointcare.net/wp-content/uploads/2009/12/TJC-Patient-Intake-Form.pdf