South Central Texas Bone and Joint Center, PA
2222 Airline Road
Suite B1
Corpus Christi, TX 78414
United States
ph: (361) 561-3500 (Appointments)
fax: (361) 561-3505 (Correspondence)
alt: 9-1-1 (Emergencies)
santos
Please e-mail us to obtain patient forms. To see Dr. Santos a patient cotract must be signed together with the patient history form seen below:
Online appointment scheduling and forms available at Medical Scheduling Hub.
Por favor comuniquense con nosotros por correo electrónico si quieren formas para el historial médico en español y el contrato con el paciente que se require antes de ver a el Dr. Santos:
You may copy and paste the medical history form provided here and fax it to our office prior to your visit or bring it with you:
Patient Name:
Cell Phone:
Date of Birth:
Where does it hurt (be specific and please describe if it radiates)?
When was the injury or when did the pain start?
How did the injury happen?
What aggravates the injury?
What helps the injury?
What treatments or surgeries have you had for this condition (if possible include dates and physicians performing treatment)?
What medicines, prescribed or over the counter have you taken for this condition?
Describe your pain: best and worst on a 1-10 scale and type of pain (sharp, dull, throbbing, etc.).
Medical History:
Do you have or have had in the past any of the following conditions (Please check any conditions you may have):
___High Blood Pressure ___Heart disease/Heart Attack/Angina ___Stroke/Carotid disease
___Diabetes Mellitus ___Insulin Use ___Foot/Ankle/Leg Ulcers
___COPD/Emphysema ___Asthma ___Chronic Bronchitis ___Home Oxygen Use
___Kidney Failure ___Kidney Stones ___Dialysis ___High Cholesterol
___Arthritis ___Steroid Use (more than 1 month) ___Lupus ___Rheumatoid Arthritis
___Thyroid Disease ___Cancer (Please describe below type and any treatment)
___Fractures (describe any treatment or surgeries below) ___Bleeding problems or tendencies
___Anesthesia Problems ___Abdominal or GI problems ___Skin Problems
Please describe any medical conditions requiring treatment of more than 1 month or requiring hospitalization in the past:
Please list all of your medicines with doses:
Please describe any surgeries you have had in the past (dates, hospital and physician performing surgeries would be helpful):
Allergies to any medicines:
Allergies to any foods or environmental allergies (such as cat or dog dander, oak, etc.):
Any tobacco use now or in the past (please describe current use and past use in terms of packs of cigarettes per day or per week and when did you start and if applicable when did you quit)?
Alcohol use (beer , wine, liquor or mixed drinks - how many on a typical week or month?)
What is your occupation and level of education?
Please use this space to comment on any of the above or include any medical conditions not mentioned above that may be relevant to your health:
Signature:
Date:
Copyright 2014, 2015, 2016, 2017 South Central Texas Bone and Joint Center, PA. All rights reserved.
South Central Texas Bone and Joint Center, PA
2222 Airline Road
Suite B1
Corpus Christi, TX 78414
United States
ph: (361) 561-3500 (Appointments)
fax: (361) 561-3505 (Correspondence)
alt: 9-1-1 (Emergencies)
santos