<p> Phoenix Thera-Lase Systems, LLC Health History Form 1 Patient Health History Form</p><p>Name: Age: Date: Past Medical History Please complete as accurately as possible. * NO MEDICAL PROBLEMS Hypertension (HBP)</p><p>Alzheimer’s Disease Hyperthyroidism</p><p>Anemia Hypothyroidism</p><p>Anxiety Disorder Joint Pain</p><p>Asthma (daily medications) Migraines</p><p>Atrial Fibrillation Mitral Valve Prolapse</p><p>Cancer Musculoskeletal Deformities, Congenital Cellulitis Panic Disorder</p><p>Chronic Obstructive Pulmonary Disease (COPD) Parkinsonism</p><p>Coagulation Defect Peptic Ulcer Disease (PUD)</p><p>Coronary Artery Disease (CAD) Pneumonia</p><p>CVA (Cerebral Vascular Accident/Stroke Psoriasis</p><p>Depressive Disorder Pulmonary embolism</p><p>Diabetes Mellitus, Type I (IDDM) Rheumatoid Arthritis (RA)</p><p>Diabetes Mellitus, Type II (NIDDM) Seizure</p><p>Diabetic Neuropathy Sickle-cell Trait</p><p>Esophageal Reflus Sleep Apnea</p><p>Gout (unsp) Thrombophlebitis (TPB)</p><p>Heart Attack (MI) Tuberculosis</p><p>Heart Disease Ulcerative Colitis</p><p>Hepatitis Urinary Tract Infection</p><p>None</p><p>Other</p><p>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</p><p>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</p><p>Ear/Nose/Throat Surgery Medications Elbow Surgery * I have no Medications</p><p>Eye Surgery * I take the following Medications</p><p>Finger Surgery Name of Medication Who prescribed it? How is it used? Dosage Qty Foot Surgery Date Started # of Refills</p><p>Gallbladder Surgery</p><p>Hand Surgery</p><p>None</p><p>Other Head Surgery Reason for taking the medication: Heart Surgery</p><p>Hip Replacement Surgery Knee Replacement Surgery </p><p>Knee Surgery </p><p>Lung Surgery</p><p>Neck Surgery Enter any additional directions indicated on your Neuro Surgery medication: </p><p>Reproductive Surgery </p><p>Allergy Other Keflex Are you ALLERGIC Levaquin to any medicine Aspirin Lipitor</p><p>Augmentin Macrodantin</p><p>Barbiturates Medrol</p><p>Betadine Morphine </p><p>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)</p><p>Tetanus Toxoid Hydrochlorothiazide Tetracyclines Hydrocodone Tylenol Iodine Ultram None Vioxx</p>