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Medical History Form
  1   Do you have now or have you ever had:   Date of Onset:     
      a.   Diabetes Mellitus                      Yes No
  If yes, duration and treatment
    b. Heart Attack Yes No
      Angina or Chest Pain Yes No
      Heart Failure Yes No
      Irregular or Rapid Heart Beat Yes No
      A Cardiac Pacemaker Inserted Yes No
    c. High blood Pressure Yes No
    d. A sroke Yes No
    e. Anemia Yes No
    f. Asthma Yes No
      Emphysema and/or bronchitis Yes No
      Pneumonia Yes No
      Tuberculosis Yes No
    g. Liver disease or jaundice Yes No
    h. Stomach or duodenal ulcer Yes No
    I. Kidney Stones or other disease Yes No
    j. Arthritis (if yes, type) Yes No
        Type
    k. Cancer or tumor Yes No
    l. Thyroid disease Yes No
    m. Seizures or a nervous breakdown Yes No
    n. Varicose veins or blood clots Yes No
    o. Bleeding disorders Yes No
    p. Transfusions of blood or plasma Yes No
    q. The following postive test Yes No
  AIDS       ARC       HIV       HEP B  
    r. Other medical problems Yes No
   
Explain
  3   Are you allergic to any medications or to any foods ? Yes No
  If so please describe the substance, date and type of reaction:
  4.   What medications are you using at the present time ? Give names and dosages.
  5.   Have you had any previous orthopaedic surgery or injuries? Yes No
  If yes, please give names of operations or injuries and dates:
  6.   What non-orthopaedic operations have you had ? Please give types and dates:
  7.   Are you a smoker ? Yes   No  
  If yes, how many cigarettes per day ?
  If no, and you smoked in the past, when did you stop ?
  8.   Have you gained or lost more than 10 pounds in the past year ? Yes   No
  If yes, please explain
  9.   Among your blood relatives is there a history of any of the following:
    a. Developmental Hip Dysplasia Yes No
    b. Club foot  Yes No
    c. Osteonecrosis of the hip Yes No
    d. Marten's Syndrome Yes No
    e. Ehler's - Danlos Syndrome Yes No
    f. Diabetes millitus Yes No
    g. Tumor or cancer Yes No
    h. High blood pressure Yes No
    i. Heart disease  Yes No
    j. Bleeding disorder Yes No
  10.   If applicable, are you pregnant ?   Yes No
  11.   Please give the name, address, and telephone number of your personal medical doctor:


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