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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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