What surgeries have you had?  Type / when /

 

doctorremarks__________________________________________________________

______________________________________________________________________________________________

 

List all previous serious accidents, serious falls, all broken bones (auto, work, home, leisure, sports, other-circle one.
What / when / symptoms / treatments

results___________________________________________________________________________________________

_______________________________________________________________________________________________

 

List all diet supplements, prescription drugs, and non-prescription drugs you take regularly and the reason taken. 
What / frequency / doctors / side effects / remarks________________________________________________________________

______________________________________________________________________________________________

 

Environment

 

Work  Please circle appropriate answer:    .Seated     Standing  -    Work Bench  -   Desk  -   Counter  -  Other_________________________

 

Job requires:  Physical exertion   -   Lifting   -  Bending  -  Stooping  -   Twisting  -   Carrying   -  Walking Standing   - 

 Other_____________________________________________________________

 

Chair:  Executive  -  Steno -   Bench  -   Stool  -   Folding   Other_________________Shoes:  High heels  -   Boots  -   Other_____________________ 

 

Lesiure:

Sendentary activities:   Standing  -  seated  -  Lying  -  TV  -  Reading  -  Card games  -  Sewing  -   Other

(describe)_______________________________________________________

 

Strenuous activities:     Exercise. Describe type, frequency and length of time.______________
_______________________________________________________________________________________

 

Sports  Describe type, frequency and length of time._____________________________________________

_______________________________________________________________________________________

 

If you have discontinued any activities, why?__________________________________________________

 

Do you physically exert yourself?  Frequently  -  Occasionally  -  Rarely  -  Never  (describe below)

______________________________________________________________________________________

 

What else should the doctor know about your health and your health history?

____________________________________________________________________________________________________

 

For office use only. DO NOT WRITE IN THIS BOX