SOS
Medical/Social History 7/11
Name: | SS#: | DOB: | ||||
Address: | ||||||
Phone Numbers: Home: Work: Cell: | ||||||
Primary Care Provider (MD): | Address: | Phone:
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State your body part, problem and all symptoms: Circle one: Left Right
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How long have you had this problem? | Prior injury to same area? Yes No
Date(s): |
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Date of Injury: Circle if applicable: Work Auto Athletic Injury
Describe:
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Treatment to date? Yes No | If yes: (circle all that apply) Medications Physical Therapy Injections Surgery | |||||
Medical Problems (circle if applicable, describe):
Blood Clots Heart Problems Lung Problems Cancer Diabetes Kidney Problems Stomach Ulcer Liver Problems Thyroid Problems Other medical problems (please list):
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Prior surgeries (please list):
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Anesthesia problems: Yes No If yes, please explain:
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Please list all current medications:
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Allergies, please list and include specific reaction to each:
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Aspirin allergy: Yes No | Latex allergy: Yes No | Penicillin allergy: Yes No | ||||
Family diseases, please list:
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Social History: Job: ________________________Duties:
Smoking: _______ Yes ______Packs per day _________No (Quit: when:______) Alcohol ________________ ________ drinks/day |
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REVIEW OF SYSTEMS: (CIRCLE ANY THAT APPLY, AND/OR ADD WHERE NECESSARY):
Constitutional: Weight Loss Weight Gain Fevers Night Sweats Fatigue Chills
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HEENT: Eyes Ears Sore Throat Ear Ringing
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Pulmonary: Shortness of Breath Asthma Emphysema Cough Pneumonia Tubercolosis Positive PPD Pulmonary Embolism
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Cardiac: Heart Attack Chest Pain Heart Failure Arrhythmia Fainting High Blood pressure Shortness of Breath on Exertion
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Gastrointestinal: Ulcers Abdominal Pain Hepatitis Jaundice Rectal Bleeding Dark Stools Nausea Vomiting Diarrhea Constipation Abdominal Mass
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Urinary: Infections Bleeding Kidney Stones Frequency Urgency
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Skin: Psoriasis Rashes Itching Skin Lesions
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Hematologic: Leukemia/Lymphoma Phlebitis Bleeding/Bruising Blood Clots
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Endocrine: Excessive thirst Weight Gain Weight Loss Goiter Changes in Hair Changes in Skin Cold Intolerance Heat Intolerance
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Musculoskeletal: Arthritis Joint Swelling Joint Pain Neck Pain Back Pain Fracture List: Joint Replacement: |
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Vascular: Aneurysm Leg Swelling Phlebitis Raynaud’s
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Immunologic: Sensitivities/Allergies
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Other: |