Download Orthopedic New Patient Health History Form

ORTHOPEDIC NEW PATIENT HEALTH HISTORY FORM
Last
Name:__________________________
First
Name:____________________________
Primary Care Physician:_____________________________
MI:_____
DOB:___________
Date last seen by PCP:_________________________________
Referred by:_____________________________________________
Phone:______________________________________
Reason for your visit today________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
PRESENT COMPLAINT
Part of Body:__________________________
□Left □Right
□Both
Specific Areas:________________________
□Gradual
□Sudden Duration:_____________ □Days □Weeks □Months □Years
□Improving
□Worse
□Stable
□Resolved □Fluctuating
Pain Scale(1-10):__________
Status:
□Burning □Dull □Sharp □Throbbing
Frequency: □Intermittent □Constant □Occasional □Rare Quality: □Aching
□Deep □Numbness □Stabbing □Shooting □Superficial
□Y □N Where?____________________________________________________________________
Does your pain radiate?
□No injury □Injury □Sports injury □Motor vehicle accident □Other______________________________________
Context:
Onset:____ /___ /_____
Describe:_____________________________________________________________________________________________
Trauma Type:
□Fall
□Running
□Direct blow
□N Year_________
□Y
History of injury to area?
Where:__________________________________
Aggravated by:
□NOTHING
□Pulling
Relieved by:
□Bending
□Stairs
□NOTHING
□Lifting
□Crush
or around______________________________
□Walking
□Sitting □Standing
□Pushing
□Other:_______________________________________________________
□Splint □Ice □Heat
□NOTHING □Bruising
□Swelling
HT:________________
Date:___/___/____
□Lifting □Movement
□OTC Medicines:___________________________
Associated Symptoms
□Twisting
□Limping
WT:________________
□Massage □Therapy □Elevation □Exercise □Stretching
□Acupuncture □Rest □Lying down □Movement □Pain Meds
□Instability □Tenderness □Weakness □Numbness
□Locking □Decreased mobility
□Stiffness
□Tingling
MEDICAL HISTORY
YOUR DOCTORS: Please list your current doctors and their specialties
1. Doctor______________
Specialty__________________
3. Doctor______________
Specialty_________________
2. Doctor______________
Specialty__________________
4. Doctor______________
Specialty_________________
MEDICAL CONDITIONS: Please list your medical conditions
1. _________________________________
4._________________________________
7._________________________________
2. _________________________________
5._________________________________
8._________________________________
3.__________________________________
6._________________________________
9._________________________________
CURRENT MEDICATIONS: Please list prescription and non-prescription meds including herbal supplements
Pharmacy:
□CVS
□Walgreens □Rite-aid
□Costco
Address:_________________________________________________
□Vons
□Ralph
□Other
Phone:_____________________________________________
Medication:____________________________________
Strength_______________
Directions_________________________________________
Medication:____________________________________
Strength_______________
Directions_________________________________________
Medication:____________________________________
Strength_______________
Directions_________________________________________
Medication:____________________________________
Strength_______________
Directions_________________________________________
Medication:____________________________________
Strength_______________
Directions_________________________________________
Medication:____________________________________
Strength_______________
Directions_________________________________________
Medication:____________________________________
Strength_______________
Directions_________________________________________
Medication:____________________________________
Strength_______________
Directions_________________________________________
ALLERGIES: Please list any medication allergies or reactions to medications/LATEX/other agents. Please indicate any reaction to anti--inflammatory
medications.
Allergy:__________________________________________________
Allergy:__________________________________________________
_
Allergy:__________________________________________________
_
Reaction:______________________________________________________
__
Reaction:______________________________________________________
__
Reaction:______________________________________________________
__
SYSTEM REVIEW: Please Check all that apply
Neurological: □Memory loss
□Fever □Weight Loss □Night sweats
□Numbness □Seizures □Tremors
HEENT:
Psychiatric:
□Headaches □Hearing loss □Vision loss
□Anxiety
□Depression
□Insomnia
Respiratory:
Hematologic:
□ Cough □Difficulty Breathing
□Bleeding
□Clotting
□Bruising
Integumentary:
Immunologic:
□Contact allergy
□Rash
□Environmental allergies
□Food allergies
Cardiovascular: □Chest Pain
Other:______________________________________________
□Leg Swelling □Irregular heartbeat
Gastrointestinal:
□ Abdominal pain □ Black tarry/bloody stools □ Diarrhea □ Nausea/Vomiting
Constitutional:
SURGERIES: Please list any surgeries you had had, including the left or right side and year.
1. Surgery_______________________
2. Surgery_______________________
4.
Surgery________________________
5.
Surgery________________________
7.
Surgery________________________
8.
Surgery________________________
3. Surgery_______________________
6.
Surgery________________________
9.
Surgery________________________
FAMILY HISTORY: Please list the status of your family members with medical conditions.
Father:
Mother:
Bro./Sis.:
Bro./Sis.:
Child
M/F:
Child
M/F:
□Alive
□Alive
□Alive
□Alive
□Alive
□Deceased
□Deceased
□Deceased
□Deceased
□Deceased
□Alive
□Deceased
Age_______
Medical Conditions
Age________
Medical Conditions
Age________
Medical Conditions
Age________
Medical Conditions
Age________
Medical Conditions
Age________
Medical Conditions
SOCIAL HISTORY: Occupation_________________________________
Tobacco Use:
□No
□Yes
□Former
Quit Date______________
Amount/Packs per day___________________
Alcohol Consumption
□No □Yes
History of Alcohol abuse:
Recreational drug
No
use:
TREATMENT HISTORY
□
Type:
Hand Dominance:
# of years_____________
□Beer
□No □Yes
□ Yes
Type:
□Right □Left
□Ambidextrous
□Cigarettes □Chew □Pipe □Cigar
□Age Started:______ □Age stopped:_______
□Wine □Hard
# per day/week/month____________
Liquor____________
Type____
Have you ever used needles?
□No □ Yes
Please complete the following sections regarding any treatment or diagnostic testing you have had in the past year.
Therapy
Date(s)
Facility
Physical
Aqua
Chiropractic
Acupuncture
Other
Diagnostic Testing
Area of Body
Date(s)
Facility
Area of Body
Date(s)
Facility
CT Scan
EMG/NCV
MRI
Other
Injections
Epidural
Cortisone/Steroid
Joint Fluid Therapy (Visco)
PRP
Year___________
Stem Cell
Other