Download Hip Intake Form

Daniel Le, M.D.
Total Joint Replacement
Hip Questionnaire
Last Name
First name
Email Address:
Date of Birth
Age
Pharmacy Phone Number:
Current Height: ___________________________
Current Weight:______________________
QUESTIONS ABOUT YOUR HIP:
Occupation:
Sports/Activities that are important to you:
Hip :
Left
Right
If Both
R worse
L worse
Describe the type of pain you are having:
Is the pain a result of an injury? Please describe:
With what activities does the pain occur?
Does the pain wake you up at night or interfere with sleep?
What makes it worse?
When did you first begin to have pain?
Do you have any known spine problems such as sciatica, radiculopathy, or spinal stenosis? Please describe.
Do you feel that one leg is longer than the other?
Have you tried…
NSAIDs
What kind?
Y
When?
N
(Eg. Aspirin, Celebrex, Ibuprofen)
Pain medications
Y
N
Steroid Injection
Y
N
Hyaluronic Acid Injection
Y
N
Physical Therapy
Y
N
Ice
Y
N
Brace
Y
N
Crutch/Walker/Cane
Y
N
(Eg. Synvisc, Hyalgan, Orthovisc, etc)
Crutch
Walker
Cane
Did it help you?
HAVE YOU HAD SURGERY ON YOUR HIP(S)?
Date
Surgery
Do you have stairs at home?
Yes
Surgeon
Clinic/Hospital
City, State
No
Who do you live with?_________________________________________
At each attribute, please circle the level that you feel best describes your condition at the present time:
(Please check only ONE)
HOW DO YOU BEST RATE YOUR PAIN:
None or I ignore it
Slight, occasional, no compromise in activity
Mild pain, no effect on average activities, rarely moderate pain with unusual activity, I might take aspirin. I
have moderate pain; it is tolerable but I am somewhat limited with ordinary activity or work. I might need
occasional pain medication stronger than aspirin.
I have significant pain, serious limitation of activities
I am totally disabled, crippled, constant pain in bed, or bedridden
HOW FAR CAN YOU WALK?
Unlimited
Six blocks (30 min)
Two or three blocks (10-15 min)
Indoors only
Bed and chair only
I PUT MY SHOES AND SOCKS ON:
Easily
With difficulty
I am unable to put them on or tie the laces
PUBLIC TRANSPORTATION:
I am/would be able to take the bus
I am/would be unable to take the bus
TO HELP ME GET AROUND, I USE:
No assistive devices
A cane or walking stick for long walks only
A cane or walking stick most of the time
One crutch
Two canes/walking sticks
Two crutches, a walker, or I am unable to walk
I USE THE STAIRS:
Normally without using the railing
Normally using a railing
In any manner
Unable to do the stairs
I CAN SIT:
Comfortably in an ordinary chair for one hour
On a high chair for 30 minutes
I am unable to sit comfortably on any chair
PAST MEDICAL HISTORY
CIRCLE any medical conditions you have or had:
NONE – I do not have any medical problems
Anemia
Diabetes
High Blood Pressure
Neurological disorder
Urinary tract infection
Angina
DVT
Hypothyroidism
Pregnant? Yes No
Ulcers
Anxiety
Diverticulitis
HIV
Pulmonary Embolism
Asthma
Emphysema
Irregular Heart beat
Reflux
Bleeding Disorder
GI bleed
Kidney failure
Rheumatoid Arthritis
Blood clot
Heart Attack
Liver problems
Seizures
Cancer - type:
Heart Failure
Lupus
Sleep Apnea
Depression
Hepatitis A, B, C
Migraines
Stroke
Please list your current medical conditions:
OTHER SURGICAL HISTORY
NONE – I have never had surgery
Surgeries or Hospitalizations
Year
Complications (if any)
MEDICATIONS
Please list or review all medications and supplements you are taking below, or attach a list to this form.
NONE – I do not take any medications on a regular basis
Medication
Dose
How often
ALLERGIES
NONE – I do not have any allergies to medications
Medication
Type of reaction
Do you have an allergy to any of the following:
Yes
No
Type of reaction
Latex
Adhesives or tape
Anesthetics
Iodine or IV contrast
Immunizations: Are your immunizations up to date?
Tetanus (Year)?
Flu Shot (Year)?
Yes
No
Pneumonia Vaccine (Year)?
FAMILY HISTORY
Do any of your family members have/use to have the following medical problems?
NONE – all my immediate relatives are in good health
Disease
Mother
Father
Siblings
Children
Heart disease / heart attack
High blood pressure
Cancer (type)
Stroke
Bleeding disorders
Seizures
Mental illness
Diabetes
SOCIAL HISTORY/HABITS
 Single
Marital Status
 Married
 Divorced
 Partnered
Part Time
Retired
Disabled
 Separated
 Widowed
Occupation:
Work status:
Full Time
Volunteer
Not Currently Employed
Who is your Primary Care Physician?______________________________________
Last visit to him/her? ____/____/_____
PLEASE CIRCLE
Do you smoke cigarettes?
Yes
No
How many packs per day?
For how many years?
Year quit?
Do you use other tobacco
products?
Do you drink alcohol?
Yes
No
Type and amount
For how many years?
Year quit?
Yes
No
How many drinks per week?
Do you use recreational or
street drugs
Yes
No
Type
How would you
describe your overall
health
Excellent
Good
Fair
Poor
REVIEW OF SYSTEMS
Please circle Yes (Y) or No (N) by all of the symptoms you might be experiencing today.
System
General Health
Symptom
Fever/chills
Symptom
Y/N
Fatigue
Symptom
Y/N
Unexpected
Y/N
weight loss
Eyes
Blurry vision
Y/N
Eye pain or redness
Y/N
Double vision
Y/N
Ears/nose/throat
Decreased hearing
Y/N
Sore throat
Y/N
Ear pain
Y/N
Cardiovascular
Chest pain
Y/N
Fainting
Y/N
Heart
palpitations
Y/N
Respiratory
Shortness of breath
Y/N
Cough
Y/N
Wheezing
Y/N
Gastrointestinal
Nausea/vomiting/diarrhea
Y/N
Heartburn/constipation
Y/N
Rectal bleeding
Y/N
Genitourinary
Pain with urinating
Y/N
Increased frequency
Y/N
incontinence
Y/N
Musculoskeletal
Joint pain or swelling
Y/N
Muscle cramps
Y/N
Muscle
weakness
Y/N
Skin
Rash
Y/N
Itching
Y/N
New lesions
Y/N
Neurologic
Numbness or tingling
Y/N
Loss of balance
Y/N
Ringing in ears
Y/N
Endocrine
Increase in urination
Y/N
Increased thirst
Y/N
Significant
weight gain
Y/N
Psychiatric
Anxiety
Y/N
Depression
Y/N
Sleep problems
Y/N
Blood system
Enlarged lymph nodes
Y/N
Easy bruising
Y/N
Easy bleeding
Y/N
Allergy/Immunology
Hay fever
Y/N
Hives
Y/N
Patient signature:________________________________________ Date:_________________________
Reviewed by: ___________________________________________ Date:_________________________