Orthopedic New Patient Health History Form

ORTHOPEDIC NEW PATIENT HEALTH HISTORY FORM

Last Name:______/ First Name:______/ MI:_____ / DOB:______
Primary Care Physician:______/ Date last seen by PCP:______
Referred by:______/ Phone:______
Reason for your visit today______
______
______
______
PRESENT COMPLAINT
Part of Body:______/ □Left / □Right / □Both / Specific Areas:______
Onset:____ /___ /_____ / □Gradual / □Sudden / Duration:______/ □Days / □Weeks / □Months / □Years
Pain Scale(1-10):______/ Status: / □Improving / □Worse / □Stable / □Resolved / □Fluctuating
Frequency: / □Intermittent / □Constant / □Occasional / □Rare / Quality: / □Aching / □Burning / □Dull / □Sharp / □Throbbing
□Deep / □Numbness / □Stabbing / □Shooting / □Superficial
Does your pain radiate? / □Y / □N / Where?______
Context: / □No injury / □Injury / □Sports injury / □Motor vehicle accident / □Other______
Describe:______
Trauma Type: / □Fall / □Running / □Direct blow / □Twisting / □Lifting / □Crush
History of injury to area? / □Y / □N / Year______
Where:______/ Date:___/___/____ / or around______
Aggravated by: / □NOTHING / □Bending / □Lifting / □Movement / □Walking / □Sitting / □Standing / □Pushing
□Pulling / □Stairs / □Other:______
Relieved by: / □NOTHING / □Splint / □Ice / □Heat / □Massage / □Therapy / □Elevation / □Exercise / □Stretching
□OTC Medicines:______/ □Acupuncture / □Rest / □Lying down / □Movement / □Pain Meds
Associated Symptoms / □NOTHING / □Bruising / □Instability / □Tenderness / □Weakness / □Numbness / □Tingling
□Swelling / □Limping / □Locking / □Decreased mobility / □Stiffness
HT:______/ WT:______

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 / □Vons / □Ralph / □Other
Address:______/ 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:______/ Reaction:______
Allergy:______/ Reaction:______
Allergy:______/ Reaction:______

SYSTEM REVIEW: Please Check all that apply

Constitutional: / □Fever / □Weight Loss / □Night sweats / Neurological: / □Memory loss / □Numbness / □Seizures / □Tremors
HEENT: / □Headaches / □Hearing loss / □Vision loss / Psychiatric: / □Anxiety / □Depression / □Insomnia
Respiratory: / □ Cough / □Difficulty Breathing / Hematologic: / □Bleeding / □Clotting / □Bruising
Integumentary: / □Contact allergy / □Rash / Immunologic: / □Environmental allergies / □Food allergies
Cardiovascular: / □Chest Pain / □Leg Swelling / □Irregular heartbeat / Other:______
Gastrointestinal: / □ Abdominal pain / □ Black tarry/bloody stools / □ Diarrhea / □ Nausea/Vomiting

SURGERIES: Please list any surgeries you had had, including the left or right side and year.

1. Surgery______/ 4. Surgery______/ 7. Surgery______
2. Surgery______/ 5. Surgery______/ 8. Surgery______
3. Surgery______/ 6. Surgery______/ 9. Surgery______

FAMILY HISTORY: Please list the status of your family members with medical conditions.

Father: / □Alive / □Deceased / Age______/ Medical Conditions
Mother: / □Alive / □Deceased / Age______/ Medical Conditions
Bro./Sis.: / □Alive / □Deceased / Age______/ Medical Conditions
Bro./Sis.: / □Alive / □Deceased / Age______/ Medical Conditions
Child M/F: / □Alive / □Deceased / Age______/ Medical Conditions
Child M/F: / □Alive / □Deceased / Age______/ Medical Conditions
SOCIAL HISTORY: Occupation______/ Hand Dominance: / □Right / □Left / □Ambidextrous
Tobacco Use: / □No / □Yes / □Former / Quit Date______/ Type: / □Cigarettes / □Chew / □Pipe / □Cigar
Amount/Packs per day______/ # of years______/ □Age Started:______/ □Age stopped:______
Alcohol Consumption / □No / □Yes / Type: / □Beer / □Wine / □Hard Liquor______/ # per day/week/month______
History of Alcohol abuse: / □No / □Yes
Recreational drug use: / □No / □ Yes / Type____ / Have you ever used needles? / □No / □ Yes / Year______

TREATMENT HISTORY

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
CT Scan
EMG/NCV
MRI
Other
Injections / Area of Body / Date(s) / Facility
Epidural
Cortisone/Steroid
Joint Fluid Therapy (Visco)
PRP
Stem Cell
Other