Health History Form s2

Phoenix Thera-Lase Systems, LLC Health History Form 1 Patient Health History Form

Name: Age: Date: Past Medical History Please complete as accurately as possible. * NO MEDICAL PROBLEMS Hypertension (HBP)

Alzheimer’s Disease Hyperthyroidism

Anemia Hypothyroidism

Anxiety Disorder Joint Pain

Asthma (daily medications) Migraines

Atrial Fibrillation Mitral Valve Prolapse

Cancer Musculoskeletal Deformities, Congenital Cellulitis Panic Disorder

Chronic Obstructive Pulmonary Disease (COPD) Parkinsonism

Coagulation Defect Peptic Ulcer Disease (PUD)

Coronary Artery Disease (CAD) Pneumonia

CVA (Cerebral Vascular Accident/Stroke Psoriasis

Depressive Disorder Pulmonary embolism

Diabetes Mellitus, Type I (IDDM) Rheumatoid Arthritis (RA)

Diabetes Mellitus, Type II (NIDDM) Seizure

Diabetic Neuropathy Sickle-cell Trait

Esophageal Reflus Sleep Apnea

Gout (unsp) Thrombophlebitis (TPB)

Heart Attack (MI) Tuberculosis

Heart Disease Ulcerative Colitis

Hepatitis Urinary Tract Infection

Past Orthopedic Medical History Please complete as accurately as possible. Phoenix Thera-Lase Systems, LLC Health History Form 2 *DENIES ANY PAST Multiple Sclerosis Pain – Forearm

ORTHOPEDIC MEDICAL Myopathy Pain – Hand/Finger PROBLEMS Osteoarthritis Pain – Hip/Thigh Bursitis Osteopenia Pain – Knee Carpal Tunnel Syndrome None Pain – Leg/Calf Cerebral Palsy Other Pain – Neck Contusion Osteoporosis Pain – Shoulder Dislocation Pain – Ankle/Foot Pain – Wrist Fibromyalgia Pain – Back Sprain/Strain Fracture Pain – Chronic Pain Swelling Ganglion Pain – Elbow/Upper Arm Herniated Disc Past Surgical History Shoulder Replacement Surgery *DENIES ANY PAST SURGERIES Skin Surgery Ankle Surgery Spine Surgery Appendectomy Stomach Surgery Arm Surgery Thigh Surgery Back Surgery Thyroid Surgery Breast Surgery Toe(s) Surgery Calf Surgery Urology Surgery Carpal Tunnel Surgery Vascular Surgery Clavicle Surgery Wrist Surgery Colon Surgery

Ear/Nose/Throat Surgery Medications Elbow Surgery * I have no Medications

Eye Surgery * I take the following Medications

Finger Surgery Name of Medication Who prescribed it? How is it used? Dosage Qty Foot Surgery Date Started # of Refills

Gallbladder Surgery

Hand Surgery

Other Head Surgery Reason for taking the medication: Heart Surgery

Hip Replacement Surgery Knee Replacement Surgery

Knee Surgery

Lung Surgery

Neck Surgery Enter any additional directions indicated on your Neuro Surgery medication:

Reproductive Surgery

Allergy Other Keflex Are you ALLERGIC Levaquin to any medicine Aspirin Lipitor

Augmentin Macrodantin

Barbiturates Medrol

Betadine Morphine

Biaxin Sulphate No Known Drug Ceclor Allergies Celebrex Nsaids Cephalosporins Penicillins Cipro Phenothiazines Codeine Plavix Phosphate Quinolones Cortisone Salicylates Demerol Statins Erythromycin Sulfa Flagyl (Sulfonamides)

Tetanus Toxoid Hydrochlorothiazide Tetracyclines Hydrocodone Tylenol Iodine Ultram None Vioxx