Date:
Name:
Date of Birth:
What is your age?
1. Please describe the reason you are here to see Dr. Eagan:
2. Date when your injury first began:
3. Did you injure yourself at or in any of the following places?
Work: Name of employer Auto related incident School: Name of school
4. Have you ever had symptoms or an injury like this before? Yes No If yes, please explain:
5. Have you been treated by another doctor or an emergency room for this injury? Yes No
Name of doctor:
Where:
Date treated:
6. Have you had blood tests or x-rays relating to this injury in the last six (6) months? Yes No
When::
7. Name of your medical or primary doctor:
8. Would you like your doctor to receive a report from Dr. Eagan regarding your care here? Yes No
9. Do you have any history of any of the following:
a) Heart Attack? When? b) Bypass Surgery? When? c) Chest Pain? When?
a) Heart Attack?
When?
b) Bypass Surgery?
c) Chest Pain?
10. Please list any serious childhood illnesses:
11. Please list any serious adult illnesses:
12. Please list all previous operations:
13. Do you have any problems with the following?
Review of systems:
YES
NO
Please Explain:
a) Skin?
b) Eyesight?
c) Ears/hearing?
d) Swallowing?
e) Coughing?
f) Shortness of Breath?
g) Change in Bowel or Bladder function?
h) Chest Pain?
i) Headaches, Seizures or Shaking?
j) Pain, Stiffness, or Numbness in arms or legs?
14. Please list all ALLERGIES, if none, please note "NONE KNOWN:"
15. Do you smoke? Yes No Amount:
16. Do you drink alcoholic beverages? Yes No Amount:
17. Please list all medications you are now taking:
Please print out this form and bring it with you for your appointment.
