Arise Recovery Centers Medical Forms

Medical History Form

Pain Assessment Form

Online Medical History Form

Patient Name

Nickname

Age

Name of Physician & Their Specialty

Most Recent Physical Examination

Purpose

Preferred Clinic Location

Insurance Policy Holder Name

Insurance Policy Holder Date of Birth

What is your estimate of your general health?

Excellent Good Fair Poor

DO YOU HAVE or HAVE YOU EVER HAD:

1. Hospitalization for illness or injury?

Yes No

3. Heart problems, or cardiac stent within the last six months?

Yes No

4. History of infective endocarditis?

Yes No

5. Artificial heart valve, repaired heart defect (PFO)?

Yes No

6. Pacemaker or implantable defibrillator?

Yes No

7. Artificial prosthesis (heart valve or joints)?

Yes No

8. Rheumatic or scarlet fever?

Yes No

9. High or low blood pressure?

Yes No

10. A stroke (taking blood thinners)?

Yes No

11. Anemia or other blood disorder?

Yes No

12. Prolonged bleeding due to a slight cut (INR > 3.5)?

Yes No

13. Emphysema, shortness of breath, sarcoidosis?

Yes No

14. Tuberculosis, measles, chicken pox?

Yes No

15. Asthma?

Yes No

16. Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)?

Yes No

17. Kidney disease?

Yes No

18. Liver disease?

Yes No

19. Jaundice?

Yes No

20. Thyroid, parathyroid disease, or calcium deficiency?

Yes No

21. Hormone deficiency?

Yes No

22. High cholesterol or taking statin drugs?

Yes No

23. Diabetes (HbA1c=)?

Yes No

24. Stomach or duodenal ulcer?

Yes No

25. Digestive disorders (i.e. celiac disease, gastric reflux)?

Yes No

26. Osteoporosis/osteopenia (i.e. taking bisphosphonates)?

Yes No

27. Arthritis, rheumatoid arthritis, lupus?

Yes No

28. Glaucoma?

Yes No

29. Contact lenses?

Yes No

30. Head or neck injuries?

Yes No

31. Epilepsy, convulsions (seizures)?

Yes No

32. Neurologic disorders (ADD/ADHD, prion disease)?

Yes No

33. Viral infections and cold sores?

Yes No

34. Any lumps or swelling in the mouth?

Yes No

35. Hives, skin rash, hay fever?

Yes No

36. STI / STD?

Yes No

37. Hepatitis?

Yes No

38. HIV / AIDS?

Yes No

39. Tumor, abnormal growth?

Yes No

40. Radiation therapy?

Yes No

41. Chemotherapy, immunosuppressive?

Yes No

42. Emotional problems?

Yes No

43. Psychiatric treatment?

Yes No

44. Antidepressant medication?

Yes No

45. Alcohol / street drug use?

Yes No

46. Presently being treated for any other illness?

Yes No

47. Aware of a change in your health in the last 24 hours?

Yes No

48. Taking medication for weight management (i.e. fen-phen)?

Yes No

49. Taking dietary supplements?

Yes No

50. Often exhausted or fatigued?

Yes No

51. Experiencing frequent headaches?

Yes No

52. A smoker, smoked previously or use smokeless tobacco?

Yes No

53. Considered a touch person?

Yes No

54. Often unhappy or depressed?

Yes No

55. FEMALE - taking birth control pills?

Yes No

56. FEMALE - pregnant?

Yes No

57. MALE - prostate disorders?

Yes No

Describe any current medical treatments:

Drug

Purpose

Drug

Purpose

Drug

Purpose

Drug

Purpose

Arise Recovery Centers Medical Forms

Medical History Form

Pain Assessment Form

Online Medical History Form

Online Pain Assessment Form