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All information is confidential and submitted securely to Methodist Sports Medicine. Please answer honestly to assure the best possible treatment for you. Please complete steps 1 - 3, you may move freely between them below. You can submit the form on the last tab.

Patient Information



(Please list all and include side(s) affected)





Race and Ethnicity
Social History














Pharmacy Information

Please provide as much information as possible in regards to your pharmacy, including the name, number, city/cross streets and/or zip code. This will help us better find your correct pharmacy location.

Current Medications


# Medication Dosage Frequency
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Allergies


# Allergy Reaction
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Previous Surgeries/Hospitalizations
Surgery Yes No
Tonsillectomy

Appendectomy

Gallbladder Removal

Hysterectomy

Hernia

Spinal Surgery

Heart Surgery

Orthopedic Surgery (1)

Orthopedic Surgery (2)

Orthopedic Surgery (3)

Other Surgery (1)

Other Surgery (2)




Medical History (Illness)
Illness Yes No Date
Deafness/Hearing Loss
Sinus Problems
Irregular Heart Rhythm
High Blood Pressure
Heart Attack
Blood Clots
High Cholesterol
Hepatitis
Anemia
Bleeding Tendency
Cancer
HIV
Hypothyroidism
Hyperthyroidism
Gout
Stroke
Seizures
Depression
Diabetes, Type 1
Diabetes, Type 2
Asthma
Lung Disorders
Tuberculosis
Acid Reflux
Ulcers
Dermatitis
Other (describe)
Medical History (Present Review of Symptoms)
Present Review of Symptoms Yes No Date
Abdominal Pain
Balance/Coordination
Chest Pain
Constipation
Corrective Lenses
Cough
Diarrhea
Dizziness
Double/Blurred Vision
Enlargement of Lymph Nodes
Fatigue
Fever
General Ill Feeling
Hallucinations
Headaches
Incontinence
Loss of Appetite
Loss of Muscle (Atrophy)
Memory Loss
Numbness in Arms/Legs
Painful Urination
Rashes/Lesions/Ulcers of Skin
Shortness of Breath
Skin Temperature Changes
Sleep Disturbances
Weight Loss
Family History


Disease Yes No
Osteoarthritis
Rheumatoid Arthritis
Hypertension
Heart Disease
Muscular Disease
Endocrine Disease
Diabetes
Cancer
Physician Information
Medical Records Upload


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