Patient Medical History Patient Medical HistoryAlain E. Elbaz, MD, PLLC Please Select which location (Cypress or Houston) 10726 Huffmeister Rd., Suite 120, Houston, TX 77065 4200 Twelve Oaks Drive, Houston, TX 77027 Date MM slash DD slash YYYY Patient Name First Last Patient Age Patient Date Of Birth MM slash DD slash YYYY Email (for office reminders/correspondence) Date Of Injury or Onset of Problem MM slash DD slash YYYY Briefly Describe Your Injury Or ProblemHave You Had Surgery For This Condition? Yes No If Yes, Please Enter Surgery Date and Surgeon Did The Injury Result From An Automobile Accident? Yes No Were you Injured At A School Activity? Yes No If Yes, Please Enter Sport Below If Yes, Please Enter School Name Below If Yes, Please Enter Trainer’s Name Below If Yes, Please Enter Coaches’ Name Below Were you Injured On The Job? Yes No Were you Injured In An Accident? Yes No Check all symptoms you are currently experiencing Allergy Cardiovascular Chest Pain Connective Tissue Disease Diabetes Mellitus Eating Disorder Ear / Nose / Throat Eye Fever Gastrointestinal Genitourinary Hemtalogical Lymphatic Musculoskeletal Pain Neurological Psychiatric Respiratory Skin Weight Gain Weight Loss Check all that apply to you Asthma / Lung Problems Cancer Cardiac Disease Diabetes History of Back Pain Hypertension Psychiatric Disorders Seizure Disorder Stroke Please list any additional medical or health problemsPlease list any surgeriesPlease list any medication allergies that you have :Please list any medications you are currently taking (and dosage if known) :If you are a woman, are you currently pregnant, or is there a possibility that you are pregnant? Yes No How Much Do You Smoke? None Less Than 5 Cigarettes A Day 5-10 Cigarettes A Day 10-20 Cigarettes A Day More Than 1 Pack A Day Are you currently using marijuana, cocaine, methamphetamine, ecstasy, narcotics, or any other drugs? Yes No Are you currently using steroids or other performance enhancing drugs? Yes No Do you feel you are at risk for falls or falling injuries? Yes No Please describe your alcohol consumption : Daily Weekly Monthly Occasionally Rarely Never I hereby authorize any physician with Alain E Elbaz MD PLLC to furnish information to insurance carriers concerning my illness or treatments. I hereby assign to the physicians all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amounts not covered by my insurance company. A copy of this authorization shall be as valid as the original. Typing my name in the space below its equivalent to signing this form.Insured’s SignatureNameThis field is for validation purposes and should be left unchanged.