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DELAWARE VALLEY ORTHOPEDIC ASSOCIATES
To ensure you receive a complete and thorough evaluation, please provide us with the important background information.
Name:______Date of Birth:______
Height:______Weight:______
Occupation:______Leisure Activities:______
MEDICAL HISTORY
ARE YOU CURRENTLY UNDER THE CARE OF: PAST MEDICAL AND PSYCHIATRIC HISTORY
Ø Medical Doctor (M.D.) Yes___No______
Ø Osteopath (D.O.) Yes___No______
Ø Dentist Yes___No______
Ø Psychiatrist Yes___No______
Ø Physical Therapist Yes___No______
Ø Chiropractor Yes___No______
REASON FOR TODAY’S VISIT:______
PLEASE ANSWER THE FOLLOWING AS THEY PERTAIN TO YOU AND YOUR HEALTH:
Yes___No___ Anemia Yes___No___ Heart Problems
Yes___No___ Arthritis Yes___No___ Heart Murmur
Yes___No___ Arthritis (Rheumatoid) Yes___No___ Heart Attack (when?)______
Yes___No___ Asthma Yes___No___ Heart Angina
Yes___No___ Emphysema/Bronchitis Yes___No___ Angioplasty
Yes___No___ Breathing Difficulties Yes___No___ Coronary Bypass Surgery
Yes___No___ Wake up short of breath Yes___No___ High Blood Pressure
Yes___No___ Use oxygen at home Yes___No___ Stroke
Yes___No___ History of ulcers Yes___No___ Fever/chills/sweats
Yes___No___ History of hernias Yes___No___ Unexplained weight loss
Yes___No___ Breathing Treatments Yes___No___ Frequent Headaches
Yes___No___ Climb 2 flights of steps without Yes___No___ Epilepsy
shortness of breath Yes___No___ Eye Problems
Yes___No___ Cancer Yes___No___ Cough
Yes___No___ Chemical Dependency Yes___No___ Cough up anything
(i.e., alcoholism, drugs) Yes___No___ Currently have a cold
Yes___No___ Diabetes Yes___No___ Abnormal chest Xray
Yes___No___ Depression Yes___No___ Kidney Disease
Yes___No___ Mental Illness Yes___No___ Hepatitis
Yes___No___ Gastro-Intestinal Problems Yes___No___ Multiple Sclerosis
Yes___No___ Jaundice Yes___No___ Tuberculosis
Yes___No___ Dentures, bridgework, loose or Yes___No___ Use cane or walker
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Yes___No___ Chip teeth, braces Yes___No___ Numbness/ weakness (legs,arms)
Yes___No___ Hearing Problems Yes___No___ Thyroid Problems
Yes___No___ Hearing Aid (bring to SPU with you) Yes___No___ Urination difficulties
Yes___No___ Vision problems Yes___No___ Skin rashes
Yes___No___ Hoarseness / throat problems Yes___No___ Other skin disorders
Yes___No___ Joint pain or swelling Yes___No___ History of Lymphoma
Yes___No___ Excessive muscle ache Yes___No___ Take blood thinners
Yes___No___ Osteoporosis Yes___No___ Tolerate lying flat
FAMILY HISTORY
HAS ANYONE IN YOUR IMMEDIATE FAMILY EVER BEEN DIAGNOSED WITH THE FOLLOWING:
Yes___No___ Anemia Yes___No___ Epilepsy
Yes___No___ Arthritis Yes___No___ Heart Problems
Yes___No___ Arthritis (Rheumatoid) Yes___No___ Hepatitis
Yes___No___ Asthma Yes___No___ High Blood Pressure
Yes___No___ Cancer Yes___No___ Kidney Disease
Yes___No___ Chemical Dependency (Alcohol, Drugs) Yes___No___ Mental Illness
Yes___No___ Chronic Cough Yes___No___ Multiple Sclerosis
Yes___No___ Depression Yes___No___ Stroke
Yes___No___ Diabetes Yes___No___ Tuberculosis
Yes___No___ Emphysema/Bronchitis Yes___No___ Thyroid Problems
Yes___No__ Problems with anesthesia
PREVIOUS HOSPITALIZATION OR SURGERY:
DATE REASON
______
______
______
Yes___No___ Problems with local anesthesia Yes___No___ Problems with general anesthesia
Yes___No___ Problems with bleeding Yes___No___ Problems with scarring or keloids
Yes___No___ Do you receive antibiotics before any dental or surgical procedures
Yes___No___ Are you extremely anxious about your pending surgery
Yes___No___ Do you need a language interpreter, if yes, please give name of the person who will
Stay with you at the hospital______
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PREVIOUS ORTHOPEDIC PROBLEMS; (fractures, sprains,dislocations, etc.)
DATE REASON
______
______
______
DO YOU SMOKE: ___Never, ___Occasionally, ___A pack or less daily, ___Two or more packs daily
DRINK ALCOHOL: ___Never, ___Occasionally, ___Two or less daily, ___Three or more daily
FEMALE PATIENTS PLEASE ANSWER:
Date of your last menstrual period______
Could you be pregnant? Yes_____No_____
PLEASE LIST ALL PRESCRIPTION MEDICATIONS (including pills, injections, and/or skin patches)
THAT YOU ARE PRESENTLY TAKING:
______
______
______
Ø ARE YOU ALLERGIC TO ANY MEDICATIONS YES_____NO______
Ø Please list:______
______
WHICH OF THE FOLLOWING OVER-THE-COUNTER MEDICATIONS ARE YOU PRESENTLY TAKING?
Yes___No___ Aspirin Yes___No___ Antihistamines
Yes___No___ Tylenol Yes___No___ Antacids
Yes___No___ Advil/Motrin/Ibuprofen Yes___No___ Laxatives
Yes___No___ Decongestants Yes___No___ Vitamin/mineral supplement
Yes___No___ Other______
Thank you J Today’s Date______