Search form
Search
Call:
785-537-4200
Text:
785-384-9315
Toll Free:
1-800-793-2141
Medical Records
Image Share
Pay Your Bill
Request Appointment
Click on the chatbot below or text us at 785-384-9315
Read More
Menu
Home
Our Practice
Physicians & Staff
Services
Physical Therapy
Resources
Blog
Contact
Search
Health History Form
Information
Visit Type
*
- Select -
First Visit
Return Visit
Name
*
Date of Birth
*
Year
Year
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Primary Care Physician
*
Referred By
*
Today's Date
*
Year
Year
2023
2024
2025
2026
2027
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
History of Present Illness
Reason for Visit
*
Side
*
Right
Left
Is this related to a
*
- Select -
Work Injury
Motor vehicle accident
Sports accident
Other
If "Other"
When did this begin?
*
If chronic, how long?
Describe how the injury occurred and how it limits your activity
*
Rate your pain at rest
*
- Select -
0
1
2
3
4
5
6
7
8
9
10
Rate your pain at worst
*
- Select -
0
1
2
3
4
5
6
7
8
9
10
Describe the pain
*
- Select -
Constant
Occasional
Is the pain
*
- Select -
Worsening
Stable
Improving
Pain character
*
Sharp
Dull
Aching
Stabbing
Throbbing
Other
Check all that apply
Pain symptom
*
Locking
Catching
Giving Way/Instability
Popping
Grinding
Bruising
Numbness
Tingling
Pain
Weakness
Swelling
Check all that apply
What, if anything, makes your symptoms better?
*
Rest
Activity
Cold/Heat Therapy
Tylenol/Ibuprofen
PT
Other
Check all that apply
What, if anything, makes your symptoms worse?
*
Inactivity
Exercise
Other
Check all that apply
Please describe any selections that made it worse
What treatments have you tried for this injury?
*
Nothing
Exercise
Ice
Decreased activity
Bracing
Injections
Physical Therapy
Medications
Other
Check all that apply
Please describe any treatment selctions
Medical History
Select any problems you currently have or have had in the past
*
Aids / HIV
Alcoholism
Anemia
Arthritis
Atrial Fibrillation
Blood clots / DVT
Cancer
Congestive Heart Failure
COPD
Depression
Diabetes
Drug abuse
Fibromyalgia
Fracture
Gout
Heart disease / attack
Heartburn
Hepatitis
High blood pressure
High cholesterol
Kidney Disease
Liver Disease
Lupus
MRSA
Osteoporosis
Pulmonary Emboli
Rheumatoid arthritis
Seizure disorders
Stomach ulcer / GERD
Stroke
Thyroid problems
Other
None apply to me
Check all that apply
If "Other"
Surgical History
Surgical History
*
Please list all previous surgeries and the approximate year. If none, write "No surgical history".
Any difficulties or complications from anesthesia?
*
- Select -
Yes
No
If "Yes", what type?
Family History
Family history
*
Ankylosing spondylitis
Asthma
Blood clots
Cancer
Diabetes
Gout
Heart disease
Hypertension
Kidney disease
Liver disease
Lupus
Osteoarthritis
Osteoporosis
Rheumatoid arthritis
Anesthesia problems
Other
Check all that apply
If "Other"
Social History
Occupation
*
Are you currently working?
*
- Select -
Yes
No
Retired
Limited duty
Recreational/Sports Activity?
*
Do you exercise?
*
- Select -
Yes
No
Exercise frequency
Marital Status
*
- Select -
Single
Married
Divorced
Widowed
Tobacco use
*
- Select -
Never
Former
Smoke
Chew
Amount?
Packs/Cans a day for how many years
Alcohol use
*
- Select -
None
Occasional
2-3
4+
Drinks per day
Caffeine
*
- Select -
Yes
No
Caffeine frequency
Recreational drugs
*
- Select -
Yes
No
Drug type
Drug frequency
Review of Systems
Are you currently experiencing any of these problems today?
*
Fatigue
Fever
Headache
Visual loss
Cough
Short of breath
Chest pain
Palpitations
Constipation
Diarrhea
Nausea / Vomiting
Painful urination
Blood in urine
Excessive thirst
Heat / Cold Intolerance
Difficulty walking
Dizziness
Skin rash
Easy bleeding
Easy clotting
Environmental allergy
Food allergy
None apply to me
Check all that apply
Allergies
Are you allergic to
*
Sulfa drugs
Penicillin (PCN)
Latex
Steroids
No known drug allergies
Check all that apply
Other medication allergies?
Add reactions to medications
Medications
List all prescriptions, over the counter, and supplements
*
Include medication, dosage, and frequency. If none, write "No medications".
Digital Signature
I attest that the above information is correct and to the best of my knowledge. I have read and understand the entire contents of the form and have had the opportunity to ask questions regarding the information of this form.
Full Name
*
Date
*
Year
Year
2023
2024
2025
2026
2027
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Testimonials & Reviews
“
Five STAR review! Thank you.
The Greatest Comebacks Begin Here!