Medical Registration (Step 2 of 2)
PATIENT NAME:
COMPLETED BY:
PAST MEDICAL HISTORY:  Please name all the medical conditions you have
PAST SURGICAL HISTORY: Please list all the surgery(s) you have undergone
MEDICATIONS:  Please list all the medications (with dosages and proper spelling) that you are taking.
ALLERGIES/ALLERGIC REACTIONS: Please list all the medications to which you are allergic and
please specify the reaction you had to the medication.
Additional History:
If you do not have a history in a specific category, for example no additional orthopedic history, please enter 'NA' or '0' in
the adjacent field.  PLEASE NOTE THAT ALL FIELDS IN BOLD PRINT must have an appropriate response chosen and
cannot be left blank; incomplete responses will delay processing of your information.
Orthopedic History
Orthopedic conditions can include
Arthritis: Shoulder, Elbow, Hand, Wrist; Hip, Knee, Ankle, Foot
Ligament Injury/ Reconstruction: Such as Shoulder or Knee Arthroscopy
Joint Replacements: Such as  total hip or shoulder replacement
Fracture Care/Surgery: Such as previous surgery or casting
Osteoporosis: Include causes of and medications being used
Cardiac/Heart History
Cardiac/Heart conditions can include
Arrythmias, Atrial Fibrillation, Coronary Artery Bypass, Congestive Heart
Failure, Previous Heart Attack, Coronary Artery Disease
Lung/Pumonary History
Lung/Pulmonary conditions can include
Asthma, COPD, Emhysema, Pneumonia, Reactive Airway Disease,
Endocrine Disorders
Endocrine/Hormonal conditions can include
Diabetes Mellitus, Thyroid Disorder, Osteoporosis, Ovarian Conditions,
Pituitary Problems
Gastrointestinal History
Gastrointestinal Conditions can include
Gastroesophogeal Reflux (GERD), Stomach Ulcers, Gallbladder
problems, Colitis, Irritable Bowel Syndrome, Crohns, Polyps, Hernias
Liver History
Liver Conditions
Hepatitis A, Hepatitis B, Hepatitis C, Viral Hepatitis
Genitourinary History
Genitourinary Conditions can include
Bladder Infections, urinary difficulties, incontinence
Females: Other Infections
Males: Prostate Conditions
Psychiatric History
Psychiatric/Psychological conditions can include
Alcoholism, Anorexia, Anxiety, Bipolar Disorder, PTSD,
Bulimia, Chemical Dependency, Depression
Neurologic History
Neurologic conditions can include
Stroke/CVA, Polio, Multiple Sclerosis
Kidney History
Kidney Conditions can include
Renal Failure, Kidney Cysts, Kidney Stones, Missing a kidney,
hemodialysis
Vascular History
Vascular Conditions can include
Arterial Disease, Venous Disease, Deep Venous Thrombosis (DVT),
Previous Angioplasty, Varicose Veins, Previous Bypass
Infectious Disease History
Infectious Disease Conditions can include
Chicken Pox, Mononucleosis, Shingles, TB, Venereal Disease, HIV,
AID's, Mumps
Blood Disorders/Lympatic Conditions
Blood Disorders/Lymphatic Conditions can include
Anemia, Blood Clots, Bleeding Disorders, Lymphatic Disorders,
Platelet Disease, Immunoglobulin Disease
Cancer History
Cancer History/Conditions can include
Breast Cancer, Bone Cancer, Colon Cancer, Lung Cancer,
Leukemia
Obstetrical/Gynecologic History
OB/GYN Conditions can include
Endometriosis, Miscarriage, Ovarian Cysts, Ovarian removal,
Hysterectomy
Review of Symptoms: Other Symptoms you may be experiencing
Please tell us additional symptoms you may be experiencing, such as chills, fever,
depression, dizziness, fainting, forgetfulness, headache, loss of sleep, loss of
weight, nervousness, sweats, blood in urine, frequent urination, painful urination,
poor bladder control, blood in stool, constipation, diarrhea, stomach pain, vomitting,
chest pain, high blood pressure, irregular heart beat, low blood pressure, poor
circulation, varicose veins, bleeding gums, nosebleeds, loss of hearing, sinus
problems, wheezing, continued coughing, history of smoking, difficulty breathing, or
other problems you may have noticed
FAMILY HISTORY:  Please state the conditions that run in your family
Other Conditions that may run in your family can include Arthritis,
Bleeding Disorders, Bone Disease, Cancer, Diabetes, Epilepsy, Heart
Disease, High Blood Pressure, Kidney Disease, Mental Illness,
Osteoporosis, Stroke,
Other Habits: Please inform us of other regular or occasional habits
Other habits can include a history of smoking, other forms of
tobacco use, alcohol use, illegal drug use, caffeine use.
Social History: Please inform us of the following information
Please let us know if you are married, single, divorced, disabled,
and/or retired
FEMALES ONLY: Are you pregnant?  Please answer as 'yes', 'no', or 'unsure'
PLEASE NOTE THAT ALL THE ABOVE FIELDS IN BOLD PRINT must have an appropriate response
chosen and cannot be left blank; incomplete responses will delay processing of your information.
                                                                                        DISCLAIMER
Please note that this online submission process is meant only to be a convenience for our patients.  It is not a substitute for the
physician-patient relationship, as face-to-face visit must be performed to review all data that has been submitted online.
All data given at this time is not considered accurate/valid until the time the physician and/or office staff has been able to review
this data, in person, with you the patient.  Receipt of any patient data without an associated, completed visit with the doctor will be
treated as any other form of unsolicited information.
With the electronic submission of this medical information, I certify that the information I have given on these pages is correct to
the best of my knowledge and that I have read and understand the above noted disclaimer.  I will not hold my doctor or any
members of his staff responsible for any errors that I may have made in completion of this form.
I understand AMC is not responsible for the data security and data integrity at the time of creation and  submission of this form,
as this process is done through a 3rd party with standard, accepted, secure channels of data transfer.

  By clicking on the 'Submit My Information' button below, I have read and understand the above Disclaimer
Click Here for General Registration, Step 1 of the two step registration process
This questionnaire on the average will take 6-7 minutes to complete.
Please complete all the sections with BOLD TYPE BY typing-in responses where required.
Please enter 'NA' or '0' if a required field does not apply to you.
You are about to start the 2nd part of a two step registration process
MY MEDICAL HISTORY
ONLINE MEDICAL INFORMATION QUESTIONNAIRE