SMART Sports Medicine Center

5307 Yellowstone Rd
Cheyenne, WY 82009
307-632-7677
www.smartsportsmedicinecenter.com

PATIENT HEALTH HISTORY 5. Past Medical History

Please Fill Out Carefully and Completely Have you ever been diagnosed with:
YES NO
Name: Ever had problems
with anesthesia? o o
Date of Birth: / / Age Heart Attack/Angina o o
1. Known Drug Allergies Heart Failure/Heart Murmur o o
High Blood Pressure o o
Stroke/TIA o o
Seizures o o
Emphysema/COPD o o
Chronic Bronchitis o o
Asthma o o
Latex Allergy o o
2. All Surgeries: Latex Sensitivity o o
Date: Describe: Kidney Failure o o
Date: Describe: Jaundice/Hepatitis o o
Cirrhosis/Liver Disease o o
Date: Describe: Diabetes o o
Blood Clots o o
3. Major Illness/ Medical Problems Anxiety/Depression o o
Date: Describe: Nervous Breakdown o o
Date: Describe: Epilepsy o o
Date: Describe: Glaucoma o o
Date: Describe: Rheumatic Fever o o
Recent Pneumonia o o
Date: Describe:
Hiatal Hernia o o
Date: Describe: Ulcer o o
4. Current Prescription and Non-Prescription Medications Thyroid Disease o o
HIV/AIDS o o
Anemia o o
Hemophilia o o
Sickle Cell Disease o o
Phlebitis o o
Cancer o o
Arthritis o o
Breast Lump o o
Skin Disease o o

Have you:
Taken Cortisone or
Steroids in the past year? o o
Ever received a
blood transfusion? o o
Patient Name:

6. Family History 8. Review of Systems

(Check All That Apply) Have you had any of the following YES NO
symptoms within the last year? ABDOMEN
YES NO
Blood Clots o o Nausea o o
YES NO
Heart Attack/Disease o o Vomiting o o
GENERAL
Cancer o o Diarrhea o o
Poor Appetite o o
Diabetes o o Constipation o o
Weight Change o o
Tuberculosis o o Blood in Stools o o
Fatigue o o
Problem with Anesthesia o o Recurrent Indigestion o o
Lung Disease o o
HEAD Gastric Reflux o o
Birth Defects o o Headaches o o Change in
Liver Disease o o EYES Bowl Movements o o
Kidney Disease o o Blurred Vision o o Abdominal Pain o o
Double Vision o o
7. Social History Contact Lenses o o GU
Do you… YES NO THROAT Urinating at Night o o
Smoke cigarettes? o o Chronic Sore Throat o o Frequent Urination o o
If yes, how many Pain or Burning on
Difficulty Swallowing o o
Packs per day?
MOUTH Urination o o
Chew tobacco? o o
Loose or False Teeth o o
Drink alcohol daily? o o HEME
If yes, how many drink Capped Teeth o o
Dental Problems o o Do you bruise easily o o
per day?
Have you ever had LUNGS Difficulty with
withdrawals? o o Stopping Bleeding o o
Shortness of Breath o o
Use “Street” Drugs< o o Chronic Cough o o
Heart GYN
Date of last menstrual period
Chest Pain o o / /
Pounding of Heart o o
Swollen Ankles o o Could you be pregnant? o o
Swollen Hands o o

Patient Signature Date

Update Medical Signature Date

Update Medical Signature Date

Update Medical Signature Date

Update Medical Signature Date

Update Medical Signature Date