Forms | Medical History | Scott L. Sledge, MD

Patient Forms

For your convenience, our forms can be downloaded on your computer and printed out for you to complete at your leisure or can be completed and submitted online. If you choose to complete the form at home please ensure to bring the completed form to your appointment. Always remember to bring your identification and insurance information to the appointment. Let us know if you have any questions or concerns and we would be more than happy to assist you. We look forward to seeing you soon!

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Online Forms

Downloadable Forms (PDF)

Medical Records Release(.pdf)

Privacy(.pdf)

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I. Patient Information

Doctor you are seeing	Patient name	Age
Gender: Male Female	DOB:
Briefly Describe Your Symptoms/Injuries
List Medications You Take Regularly
		Continue to next section

II. Allergies and Medical History

Medication Allergies
Describe Reactions
Do you Smoke? Yes No	How Many Per Day?
Do You Drink? Yes No	Drinks Per Week
Do you use illicit drugs? Yes No
Date of Last Physical	Done By
Did Physical Include:	Chest X-Ray EKG Blood Work
Have You Ever Received Blood	When	For
Have You Ever Had	Anemia Bursitis Epilepsy Hepatitis Stroke Asthma Cancer Gout Hypertension Tendonitis Heart Trouble Cardiologist	Bone or Joint Disease Colon/Intestinal Disorders HIV Tuberculosis Venereal Disease Broken Bones Diabetes Hemophilia Kidney Disease Ulcers Other
		Continue to next section

III. Surgeries and Hospitalizations

Please list previous surgeries and hospitalizations for the past 5 years
Year	Hospital	Doctor
Reason
Year	Hospital	Doctor
Reason
Year	Hospital	Doctor
Reason
Year	Hospital	Doctor
Reason
Year	Hospital	Doctor
Reason

Dr. Scott L. Sledge, MD | Orthopaedic Surgeon - San Antonio, Texas

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Please list previous surgeries and hospitalizations for the past 5 years