PMG Physiatry Dr. Ben Branch, D.O. Physical Medicine and Rehabilitation 1698 E McAndrews Rd Suite 170 Medford, Oregon 97504 541-732-8360 Name _____________________________ Birth date________________ Age______ Contact Phone ______________________ Primary Doctor _________________________ Referring Doctor ________________________ Caregiver’s Name _______________________ Date: __________________ Health History Form Reason for coming to the office today: ______________________________________________________________ When I leave the office today, I would like to have accomplished: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have you had prior treatment/therapy for this problem? Yes No Explain: __________________________________________________________________________________________ __________________________________________________________________________________________ What, if anything, helped? _____________________________________________________________________ Have you seen other physicians for this problem? Yes Whom____________________________________ ____________________________________ No _________________________________ _________________________________ Explain how the problem you are being seen for is affecting your daily life? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ What are you limited in doing currently that you would like to do again? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Past Surgical History: Date __________________ __________________ __________________ Operation _________________________ _________________________ _________________________ Complications ____________________________ ____________________________ ____________________________ Past History: k -Type: ______________ Systemic Lupus Erythematous Review of Systems: Do you currently have any of the following: GENERAL DIGESTIVE YES NO MUSCULOSKELETAL YES NO YES NO YES NO Poor appetite Weight loss Frac Change in lymph nodes Trouble sleeping Pain He BLOOD YES NO GENITOURINARY YES NO NEUROLOGICAL Infections CARDIOVASCULAR YES Dizz NO Urination at night: # times_____ in arms/legs RESPIRATORY YES NO ENDOCRINE PSYCHOLOGICAL YES NO YES Wheezing Hours of sleep without interruptions__________ EARS/NOSE/THROAT YES NO EYES YES Difficulty Hearin NO Depression NO SKIN AND BREASTS Blind spo Last Eye Exam______________ YES Rashes NO Family History: _____ Social History: Tobacco Use Alcohol Use Illicit Drug Use (Cocaine, Meth, Marijuana, etc.) City where you live Occupation ______________________________ Live in: House Condo Apartment How often do you exercise? None Last day worked _____________________________________________ _______________ Trailer/RV 1-2 week Number of Stairs_____ Elevator: Yes No 2-4 week every day Are you able to speak for yourself? Yes Are you able to perform your activities of daily living? Yes Are you currently involved in a legal case regarding today’s problem? Yes Is this a worker’s compensation case? Yes Have you or are you applying for disability? Yes Type________________________ No No No No No Medications/Dose (Current medications only, including over the counter medications): _______________________________ _______________________________ ______________________________ ______________________________ _______________________________ _______________________________ ______________________________ ______________________________ _______________________________ _______________________________ ______________________________ ______________________________ Allergies and Adverse Reactions: Medication Type of Reactions _____________________________________________ __________________________________________________ _____________________________________________ __________________________________________________ _____________________________________________ __________________________________________________ Patient Signature: __________________________________________ Date: _____________________ Thank you for your time in filling out this information. Physician Signature: ________________________________________ Date: ______________________