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Justin Siebler, M.D. Orthopaedic Traumatology Rachael McMillin, RN 402-559-8095 ORTHOPAEDICS Patient Information General Orthopaedics Name: ____________________________ Age: ________________ Date: _________________ ___________ What doctor referred you to the Orthopaedic Clinic? ____________________________________________________________________________________________________ Name of doctor treating your general health problems ____________________________________________________________ May we send them a report of this visit and subsequent visits? _____Y _____N YOUR CURRENT PROBLEM: What brought you to the clinic today? _________________________________________________________________________ What date did the problem/injury start? _______________________________________________________________________ Did the problem start suddenly? _____Y _____N or Gradually? _____Y _____N How have you treated the problem? __________________________________________________________________________ Briefly describe your problem including all symptoms and areas affected, type of pain, any swelling or numbness: ______________________________________________________________________________________________ GENERAL INFORMATION: What is your occupation? __________________________________________________________ Single _________ Married __________ Divorced __________ Widowed __________ What level of activity is required in your workplace: mild _________ moderate _________ extensive _________ What would you like us to do for you? _______________________________________________________________________ MEDICAL HISTORY: Weight __________ Height ___________ Drug Allergies or Severe Reactions None __________ If yes, please list below: Drug/Product What happened? Current Medications, including over-the-counter and prescription medications Drug and dosage How often do you take? What is it for? te te a use a Internal use: Page 1 of 3 MRN: Orthopaedic Clinic | 989265 Nebraska Medical Center | Omaha, NE 68198-9265 PH: 402-559-8000 | FX: 402-559-8746 | www.unmc.edu/orthosurgery Justin Siebler, M.D. Orthopaedic Traumatology Rachael McMillin, RN 402-559-8095 ORTHOPAEDICS Hospitalizations, surgeries and medical conditions Year Why hospitalized/what surgery? SOCIAL HISTORY Do you use tobacco now? _____Y _____N How long have you used tobacco? _____________________________________________________________________ Do you drink alcoholic beverages? _____Y In the past? _____Y _____N _____N If so, type and daily amount ____________ In the past? _____Y _____N If so, type and daily amount _______ ____________________________________________________________________________________________________ How long have you used alcohol? ___________________ Do you use any street drugs (marijuana, meth, cocaine, LSD, etc)? _____Y Do you or a family member have any problems with anesthesia? _____Y _____N _____N In the past? _____Y _____N If so, what? ______________________ FAMILY HISTORY Please mark if any of the following illnesses have occurred in any of your blood relatives: Illness Diabetes Heart disease Cancer Stroke Bleeding tendencies Yes No Relationship to you Is your father living? __Y __N Health or cause of death: ____________________ ________________________________________ Is your mother living? __Y __N Health or cause of death: ____________________ _________________________________________ Allergies Arthritis High Blood Pressure Kidney disease Mental disorders Brothers and sisters? _________________________ Any children? __Y __N If so, age and health: _______________________ _________________________________________ Tuberculosis Page 2 of 3 Orthopaedic Clinic | 989265 Nebraska Medical Center | Omaha, NE 68198-9265 PH: 402-559-8000 | FX: 402-559-8746 | www.unmc.edu/orthosurgery Justin Siebler, M.D. Orthopaedic Traumatology Rachael McMillin, RN 402-559-8095 ORTHOPAEDICS REVIEW OF SYSTEMS Please circle if you are currently experiencing or have had any of the following: Weight loss Skin disorders Night sweats Gallbladder problems Glaucoma Cataracts Hearing loss Ringing in ears Balance disturbance Throat pain Bleeding gums Chest pain or angina Heart attack Pacemaker/ICD Leg/ankle swelling High blood pressure Irregular pulse Heart murmur High cholesterol Blood clots (leg/lung) Asthma Emphysema Fibromyalgia Shortness of breath Bronchitis Pneumonia Bloody sputum Tuberculosis Ulcers Pain with eating Nausea/vomiting Heartburn/gastric reflux Liver disease Rectal bleeding Chills/Fever Change in bowel habits Black tarry stools Kidney stones Double vision Frequent urination Blood in urine Arthritis Chronic cough Swollen/painful joints Prosthesis/implants Diabetes Thyroid problems HIV/Hepatitis Epilepsy/seizures Stroke Migraines Muscle pain Hepatitis Anxiety Depression Difficulty sleeping Anemia Urinary tract infections Sickle cell disease Hemophilia Blood disease Bruising Venereal diseases Osteoporosis Back disorder COPD Tired Rheumatoid arthritis Cancer/location _________________________________________________________________________________ Foot problems ___________________________ Numbness/tingling/weakness in arms/legs ___________________ Broken bones/list ______________________________________________________________________________ Injections/location ______________________________________________________________________________ Orthopaedic Clinic | 989265 Nebraska Medical Center | Omaha, NE 68198-9265 Page 3 of 3 PH: 402-559-8000 | FX: 402-559-8746 | www.unmc.edu/orthosurgery
