Patient Medical History Form

Name

Email

Birthday & Additional Info

Primary Reason for Appointment

Please list a single problem here

How long have you had this problem?

Have you received treatment before?

Check any of the following that you have already had done: X-RayMRIInjectionPrior SurgeryPhysical Therapy

(If yes to any of imaging/injections/surgery, please have records sent before appointment)

Please list all current medications and dosages (attach list if necessary)

Are you on any blood thinners? YesNo

Please list any allergies

Are you allergic to Latex? YesNo

Past Surgical History

Please list all orthopedic surgeries, surgeon performed by and date

Please list all other surgical history:

Social History

Do you consume alcohol?
YesNo

At what frequency?
DailySocialQuantityOccasionally

Do you consume tobacco?
YesNo

At what frequency?
DailyOccasionally

Do you live in a smoke-free home?
YesNo

Family History of Diseases

Blood disorder diagnosis:

Eye, ear, nose, throat diagnosis:

Heart disease diagnosis:

Kidney disease diagnosis:

Liver disease diagnosis:

Lung disease diagnosis:

Skin disease diagnosis:

Stomach disease diagnosis:

Other autoimmune disease diagnosis:

Review of Systems

Please check all that apply.

Neurologic
HeadachesDizzinessNumbness or tingling

Other

I, certify that this information is to the best of my knowledge and believe is true, correct and complete.

Patient or Guardian Signature

Date:

AUDIO AND VIDEO RECORDING POLICY: I, the patient or patient's representative, agree to refrain from audio and or video recording of this and any interaction held between, myself as the patient or representative, with Richard Kim Medicine. For the explicit reason of quality, safety, and HIPAA compliance I understand that the nature of recordings, either visual and/or audio, can be manipulated, misconstrued, and misinterpreted. Therefore, I, as the patient or as the patient's representative, understand that failure to acknowledge and sign to this agreement may result in termination of physician/patient relationship. I am, however, eligible to obtain a copy of the paper medical records, in its entirety.

Patient or Guardian Signature:

Date:

Attach health records here if necessary
Note: All records uploaded must be in PDF format and no larger than 5 MB each.