CHRIS S. PALLIA, MD

Orthopedic and Arthroscopic Surgery

PATIENT INTAKE SHEET

Name:______ Sex: M F

Age: ______Height: ______Weight: ______ Handedness: R L

Reason for being seen:

______

______

Approximate date of onset: ______

Referred by:______Primary Care Physician: ______

Have you had surgery for this problem (What, where and when)?

______

Have you had any of the following performed for this problem?

X-ray MRI CT Scan EMG Other______

Where and when?______

Cortisone injections? Yes No # of injections: _____ Dates:______

Medications for this problem:______

______

Have you had physical therapy for this problem? YES NO

Sports in which you participate(Please specify frequency):

______

______

PAST MEDICAL HISTORY (Please check all that apply):

HeartAsthma

Coronary Artery Disease High CholesterolThyroid Disease

Arrhythmia (PVC or Afib)LungsSleep Apnea

Osteoporosis COPDLiver

Blood clots (Where?______) TB

KidneyUlcers / RefluxPoor circulation

Blood pressure(High/Low)Diabetes(Insulin Y/N) Arthritis

PsoriasisCancer(Where?______) Seizures

StrokeInfectionsAnemia

Bleeding DisorderBlood clotsPsychiatric

HepatitisA B CImmune Deficiencies Depression/Anxiety

Other______

PAST SURGERIES (Please include approximate dates):

______

What complications have you had from surgery or anesthesia, if any? ______

CURRENT MEDICATIONS: VITAMINS/SUPPLEMENTS:

______

______

______

______

DRUGALLERGIES : ______

OTHER ALLERGIES:  Iodine  Nickel Environmental Latex

Sensitivity to costume jewelry

SOCIAL HISTORY (Please circle one in each category):

CAFFEINE USE: Coffee Tea Soda : # of cups per day _____ None

TOBACCO: Years? ____ Packs/day_____ QuitWhen______Electronic None

ALCOHOL : Heavy Moderate Social Occasional Minimal None

OTHERSUBSTANCE USE: Type?______Frequency______None

REVIEW OF SYSTEMS:

Please circle any of the following symptoms that you have had in the last week:

GENERALSKINHEADEYES/VISION

FeverSkin diseaseHeadachesBlurred/double vision

WeaknessPigmentation changesLoss of memoryDecreased vision

Fatiguetumors/cancersProblem ConcentratingItching, burning, tearing

Appetite losscystsLight sensitivity

Nighttime sweats

Shaking / chills

CARDIOVASCULARRESPIRATORYGASTROINTESTINALEARS/NOSE/THROAT

Chest painChronic coughFrequent indigestionEar pain

Heart palpitationsAsthmaNausea or vomitingInfection or discharge

High blood pressureEmphysemaAbdominal painHearing decreased/ loss

Shortness of breathChronic bronchitisFrequent constipationRinging in ears

Feet/ankle swellingPneumoniaFrequent diarrheaRecurrent throat issues

Varicose veinsTuberculosisBlood in stoolsVoice Changes

Coughing bloodDental disease

WheezingSinus problems

GENITOURINARYMUSCULOSKELETALNEUROLOGIC

Painful/difficult urinationOther non-injury related issuesConvulsions

Blood in urineMultiple joint painsLoss of consciousness

Urine incontinencePain / cramping in calfOther non-injury issues

PSYCHIATRICENDOCRINEHEMATOLIC

DepressionIncreased thirstBleeding gums

NervousnessIncreased appetiteEasy bruising/bleeding

Sleeping all dayIncreased urination that’s hard to stop

Sleep DisturbanceDiabetes

Spontaneous cryingHair loss

Emotional outburst

Thoughts of suicide

FAMILY HISTORY:

 ArthritisStrokeObesity

CancerSickle Cell DiseasePsychiatric Problems

DiabetesRheumatoid ArthritisLiver Disease

Heart AttackHigh Blood PressureKidney Disease

Heart Failure

______

Signature Date