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:

admin@sctbjc.com

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:

admin@sctbjc.com

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:

SCTBJC Patient History Form

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: