Orthopedic and Health History Forms
description
Transcript of Orthopedic and Health History Forms
ORTHOPEDIC HISTORY Name: _________________________________________ Today’s Date: ________________
Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs
Primary Doctor Name and Address: Referring Doctor Name and Address:
______________________________________ ______________________________________
______________________________________ ______________________________________
If not referred, how did you choose this office? ____________________________________________
Why are you seeing the doctor today? (body part) __________________________________________
How long has the pain/problem been present? _____________________________________________
Has the pain/problem worsened recently? No Yes, how recently?________________________
What started the pain/problem? ________________________________________________________
Quality of the pain: Sharp Burning Dull Aching
How severe is the pain at the location described above?
No Pain Mild Moderate Severe
What makes the pain/problem better? ___________________________________________________
What makes the pain/problem worse? ___________________________________________________
Is the pain (check all that apply): Continuous Activity Related Night Pain Unpredictable
Did this problem start at work? ________________________________________________________
Have you already filed or will you file a Workers’ Compensation claim? _______________________
Have you missed work because of this problem? __________________________________________
What ever treatments have you tried?
Physical Therapy/Exercise TENS unit Narcotic medications Cass/boot
Massage/Ultrasound Traction Anti-Inflammatories Orthotics
Manipulation Surgery Steroid injections Braces
Are you right hand ___ or left ___?
Previous physicians seen for this problem Physician Specialty City Treatment
ORTHOPEDIC HISTORY Medications take for this problem
Name of Medication Dose Reason
X-Rays and Tests for this problem:
Results Date Location
X-Rays
MRI
CT Scan
Bone Scan
Other
Because of this problem, have you filed or do you plan to file a lawsuit? Yes No
If you are a new patient to our practice, please complete the Comprehensive Health History. If you
have previously completed a Comprehensive Health History during a visit to our practice, have there
been any changes to your medical history, surgical history or medications since that time? Please
describe any changes below:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Responsible party’s signature :____________________________________
FOR OFFICE USE ONLY I have read and confirmed the above information with the patient. X __________________________________________________
Alton Orthopedic Clinic
John Stirnaman MD - Board Certified Orthopedic Surgeon
Michael Taylor MD - Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD - Rheumatologist
Donald LeMoine PA-C
#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002
COMPREHENSIVE HEALTH HISTORY Name: _________________________________________ Today’s Date: ________________
Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs
Primary Doctor Name and Address: Preferred Pharmacy (Address/Phone)
______________________________________ ______________________________________
______________________________________ ______________________________________
PAST MEDICAL HISTORY: Check all that apply None Apply
Heart attack Asthma Rheumatoid arthritis Depression
Heart failure Tuberculosis Osteoarthritis ADHD
Abnormal heartbeat Emphysema Gout Seizures
High blood pressure Thyroid Osteoporosis Migraine
Stroke Stomach ulcers Cirrhosis Cerebral palsy
Blood clots in leg Gastric reflux Hepatitis (A, B or C) Downs syndrome
Blood clots in lung Hiatal hernia HIV/AIDS Spina bifida
Poor circulation Kidney failure Bleeding disorder Neurofibromatosis
High cholesterol Kidney stones Anemia
Neuropathy: Hands or Feet
Cancer: _________________________________________________________(type/treatment)
Diabetes: year diagnosed __________
Currently controlled with insulin oral medications diet Other: __________________________________________________________________________
__________________________________________________________________________________ PAST SURGICAL HISTORY: No Prior Surgery
latipsoH/noegruS etaD noitarepO
Have you every had general anesthesia? No Yes If yes, have you had any problems related to this? No Yes Please explain any problems related to general anesthesia: ___________________________________ __________________________________________________________________________________
Alton Orthopedic Clinic
John Stirnaman MD - Board Certified Orthopedic Surgeon
Michael Taylor MD - Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD - Rheumatologist
Donald LeMoine PA-C
#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002
COMPREHENSIVE HEALTH HISTORY MEDICATIONS (prescribed and over the counter): I take no medications
METAL ALLERGIES: No Allergies YES_______________________________(List Metals)
SOCIAL HISTORY:
Work status
Working Homemaker Unemployed Disables On Leave Retired Student
Occupation_________________________________________________________________________
Marital Status: Single Married Divorced Widowed
Children No Yes, How many? ______
Do you live alone? ______ If no, who lives with you? ______________________________________
Are you currently smoking?_____ If yes, how many packs a day?___ For how many years?_______
How many packs a day did you previously smoke? ___ Other forms of tobacco? ________________
Alcohol Use Never Rare Social Frequently (more than twice a week) Alcoholic Recovering Alcoholic Illegal Drug Use Never In the past Currently Types of Drugs_____________________
Name of Medication Dose Reason
ALLERGIES TO MEDICATIONS: No Allergies
Name of Medication Reaction (rash, swelling, stomach upset, etc.)
Alton Orthopedic Clinic
John Stirnaman MD - Board Certified Orthopedic Surgeon
Michael Taylor MD - Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD - Rheumatologist
Donald LeMoine PA-C
#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002
COMPREHENSIVE HEALTH HISTORY FAMILY HISTORY: Check all that apply None Apply
Heart problems Diabetes Arthritis Bleeding problems
Seizure Cancer High Blood Pressure Stroke
Gout Kidney problems Lung problems Mental Illness
msilohoclA Blood clots (legs or lungs
Other: _____________________________________________________________________________
REVIEW OF SYSTEMS: (In the past 30 days have you experienced any of the following?)
Fever Sleep apnea (snoring) Nausea
Chills Hoarseness Vomiting
Weight loss Cough Diarrhea
Vision changes Trouble swallowing Constipation
Vision changes Chest pain Hemorrhoids
Glasses/Contacts Palpitations Stomach pain
Hearing loss Swollen ankles Urinary difficulty
Dizziness Shortness of breath Anxiety
Ear pain Seasonal allergies Hyperactivity
Nosebleeds Skin rashes Memory loss
Toothache Swollen glands Blackouts
Gum problems Poor appetite Headache
I have not experienced any of the above symptoms in the last 30 days
Other: __________________________________________________________________________
__________________________________________________________________________________
FOR OFFICE USE ONLY I have read and confirmed the above information with the patient/family: Physician Signature:_______________________________________ Date:_______________________