Medical History Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastHave you ever been told you have any of the following?Cancer *YesNoHeart Bypass *YesNoCongestive Heart Failure *YesNoCardiac Stents *YesNoHigh Blood Pressure *YesNoLow Blood Pressure *YesNoAsthma *YesNoDiabetes *YesNoOsteoporosis *YesNoThyroid Problems *YesNoArthritis *YesNoPacemaker/Defibrillator *YesNoBlood Clot *YesNoDepression/Anxiety *YesNoDialysis *YesNoCOPD *YesNoRecent Weight Loss *YesNoHernia *YesNoAllergy to Heat/Ice *YesNoHepatitis *YesNoBowel/Bladder Problem *YesNoShingles *YesNoFibromyalgia *YesNoKidney Disease *YesNoStroke *YesNoSeizures/Epilepsy *YesNoLatex Allergy *YesNoOtherCurrently, are you experiencing any of the following? (check all that apply): *Fever/Chills/SweatsNumbness/TinglingCirculation ProblemsDizzinessPoor balance (falls)IncontinenceShortness of breathNausea/VomitingUnexplained weight lossDifficulty SwallowingBlood ClotHeadachesPregnancyHave you ever been told you have any of the following? (IF YES YOU WILL NEED TO FILL OUT ADDITIONAL INFORMATION- PLEASE SEE RECEPTIONIST FOR SECONDARY FORMH1N1 *YesNoMRSA *YesNoScabies *YesNoTB *YesNoCurrent Cough or Cold *YesNoVRE *YesNoCurrent Open Wound *YesNoPink Eye *YesNoLice *YesNoCurrent Shingles *YesNoHistory of fractured bones (If yes, please list where below with approximate dates)?Any metal implants, loop recorder, baclofen pump, insulin pump (If yes please list which and location below)?Please list any lifting, weight-bearing, or other restrictions/precautions related to your condition that have been given you by your physician:Please list your surgical history with approximate dates:Please list your current medications:Please check any of the following that you have recently had:X-RayCAT ScanPET ScanEMGMRIOther Diagnostic TestingPlease list results from any above checked testing (if known):Is there anything else you think we should know about your general health or current condition?How did you hear about Paramount please check all that apply:My Doctor Recommended ParamountFamily or Friend Recommended ParamountWebsitePast PatientFacebookDrove ByOtherIf other please specify:Please check below if you would like to receive the following types of reminders for each scheduled appointment:Phone Call RemindersText RemindersEmail RemindersSubmit
