*Comprehensive Adult New Patient Health Information*
William W. Winternitz Jr. M.D.
DATE ______
Name:______Age______Height______Weight______
Side of Injury: Right______Left______
Dominant Hand R L
Family Physician ______Referring Physician______
Reason For Visit/What Bothers You Now?______
______
______
Date of Injury or Duration of Symptoms:______
How did The Injury Occur?______
______
What Makes Your Pain Worse? ______
______
What Makes Your Pain Better? ______
______
Pain Scale: 1 2 3 4 5 6 7 8 9 10
Least Moderate Severe
What Treatment Have You Had For Your Injury? ______
______
Who Were Your Treating Doctors? ______
______
Any prior history of injury to the affected area? Yes No
Work Related? Yes No
Any Prior Studies Performed? X-rays MRI CT scan Bone Scan EMG
page 2
MEDICAL HISTORY:
___Check here if all negative
___High Blood Pressure ___Hepatitis ___Phlebitis/blood clots
___Diabetes ___Ulcer Disease ___Stroke
___Heart Disease ___Bleeding Disorder ___Kidney Stones
___Heart Attack ___Seizures ___Prostate Problems
___Heart Arrhythmia ___Thyroid Problems ___HIV
___Asthma ___Osteoporosis
___Emphysema ___Cancer______
SURGICAL HISTORY:
___Check here none
YEAR PROCEDURE YEAR PROCEDURE
______
______
HOSPITALIZATIONS: ______
CURRENT MEDICATIONS:
____Check here if none
NAME OF DRUG DOSAGE (mg) TIMES PER DAY
______
______
______
______
______
______
______
______
page 3
ALLERGIES:
___Check here if none
Foods______Dust ___Pollen ___Cats ___Dogs
___Latex ___Iodine ___Adhesive Tape
Medicines: ___Penicillin ___Sulfa Other: ______
SOCIAL HISTORY:
Occupation: full time part time
Education ______grade _____high school ____college ____post graduate
Single ____married ___committed ___divorced other______
CHILDREN ____none ____number
TOBACCO ____never____stopped ______year Currently smoking____packs per day times ____years
ALCOHOL ___none ____few per month ____1/week _____few per week ____daily
DRUG USE ___none other______
EXERCISE ___none ___1/month ___few times per week ___daily
ADAPTIVE DEVICES:
___check here if none
___foot support / orthotic ___ankle brace / AFO ___corset ___spine brace other______
___crutches ___ walker ___ wheel chair other______
FAMILY HISTORY:
Mother ___alive ___deceased cause______
Father ___ alive ___deceased cause______
Number of siblings _____
Family Medical Problems ___diabetes ___heart disease ___cancer ___spine problems
other______
page 4
REVIEW OF SYSTEMS:
Is your health ___excellent ___good ___ fair ___poor
Do you have any of the following symptoms?
___NONE Constitutional: ___fever ___weight loss ___tiredness______
___NONE Eyes: ___glasses ___blurred vision ___double vision
___NONE Ears\Nose\Throat: ___deafness ___sinus infection ___ringing ___hoarseness
___dizziness ___difficulty swallowing
___NONE Heart: ___chest pain ___irregular heart beat ___pounding in chest
___NONE Lungs: ___shortness of breath ___wheezing ___cough ___cough up blood
___NONE Abdomen: ___loss of appetite ___diarrhea ___constipation ___abdominal pain
___blood in stool ___black bowel movements
___NONE Urinary: ___burning ___loss of urine ___difficulty voiding ___infections
___blood in urine
___NONE Menstrual: ___regular ___irregular ___severe pain ___post menopausal
___NONE Musculoskeletal: ___sprains ___swelling ___arthritis ___stiffness
___NONE Skin/Breast: ___rash ___skin ulcers ___sores ___lumps ___birthmarks ___masses
___NONE Neurologic: ___balance problems ___memory problems
___NONE Behavioral: ___depression ____anxiety ___sleep disturbance ___hallucinations
___claustrophobia
___NONE Endocrine: ___hair growth/loss ___crave fluids/food ___hyperactive ___sleep all the time
___NONE Blood/Lymphatics: ____easy bruising ___anemia ___enlarged glands
___NONE Immunologic: ______itching ______frequent colds/infections