Patient History Form

Oak Cliff Orthopaedic Associates
810 N. Zang Blvd.
Dallas, Texas 75208
214-941-4243

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The Following Questions Are Designed To Aid Your Physicians In Your Care. Please Fill In Completely And Return To The Receptionist As Soon As Possible.
Name: Age: Referring Physician:
Have You Had Or Still Have	Yes	No		Yes	No
1. A recent cold			2. Bronchitis, or chronic cough
3. Asthma			4. Hayfever
5. Pneumonia			6. Tuberculosis
7. Emphysema			8. Shortness of breath
9. Any other lung trouble			10. Do you smoke?
11. Rheumatic fever			12. Heart murmur
13. High blood pressure			14. Low blood pressure
15. Chest pain. angina			16. heart attack(s)
17. Palpitations'. irregular or fast heartbeat			18. Anemia or bleeding problems
19. Sickle cell illness			20. Jaundice, hepatitis, liver trouble
21.Infectious mononucleosis			22. gallbladder trouble
23. Back pain or injury			24. Slipped disc, sciatica
25. Convulsions, epilepsy			26. Stroke
27. Polio, paralysis. meningitis			28. Thyroid trouble
29. Diabetes			30. Low blood sugar
31. Kidney trouble			32. Serious illness during pregnancy
33. Could you be pregnant?			34. Do you drink alcoholic beverages?
Other illness not mentioned above?
35. Have you had blood transfusions?			36. Do you have any caps, dentures or loose teeth?
37. Are you allergic to any medication?			38. Have you or your family had an unusual reaction to anesthesia?
39. Have you ever had any Surgery?
Type			Date




40. Please list name and dosage of all current medications:
			Name	Dosage
for blood pressure
diuretics (water pills)
antidepressants
tranquilizers or sedatives
blood thinners
eye drops
pain pills or shots
steroids, cortisones, ACTH
insulin (what kind)
other diabetic medication
sleeping tablets
other medications
				Yes	No
41. Do you take (or have you taken) any addicting drugs?
42. Other