Microsoft word - 2010-07-new patient.doc

Patient Name: ________________________________________________________ NEW PATIENT MEDICAL HISTORY FORM -07/2010

Are you Right handed Left Handed both/ambidextrous

Your family doctor is ___________________their office is in the city and state of ______________

What caused your pain? CAR ACCIDENT WORKERS COMP OTHER _______________
Please draw on the figure where the pain is/where it travels/radiates to R L L R
(example, back going down right leg to the foot) The pain came on suddenly gradually when? ___________________ suddenly gradually when? ________________ If more than one location, what percentage of your pain is where? (example 90% back 10% legs) ________________________________ Describe your pain. Check all that apply and if there is a space provided, say where on your body: Electric shocks _________ Tingling _____________ Cramping Throbbing Sore Pins / needles __________ Numb ______________ Shooting ______________ OTHER (describe):_____________________________________ From 0 to 10, what does your pain range from during the day? (0 = no pain, 10 = unbearable)______ What makes it worse? (Check all that apply) OTHER (describe):______________________________________________________________ What makes it better? (Check all that apply) OTHER (describe): ______________________________________________________________ Is your pain ALL THE TIME HAS FLARE UPS BOTH: if flare ups, when? __________ G.M.O. This page has been reviewed ____________Date_________ Patient Name: ________________________________________________________ NEW PATIENT MEDICAL HISTORY FORM -07/2010
LIST ALL MEDICINES (psychiatric, diabetes, pain, etc.) YOU ARE TAKING OVER THE
COUNTER OR FROM OTHER (NOT-Greater Metropolitan Orthopaedics) DOCTORS:
No changes since last seen in a Greater Metropolitan Orthopaedics office so don’t need to write
See the list I brought with me
Anticoagulant/Anti-platelet Medicine (Check all that apply):
Warfarin (Coumadin) Clopidogrel (Plavix)
Aggrenox / Any other blood thinners______ Medication Medication Medication Medication
Do you have any ALLERGIES to the following medications or items?
------------------------------------------------------------------------------------------------------------------------- Are you satisfied on your current pain meds? _________ Do you have enough medication? ______ What PAIN MEDICATIONS have you tried and STOPPED taking? Stopped because (side effect of, no relief, etc.) G.M.O. This page has been reviewed ____________Date_________ Patient Name: ________________________________________________________ NEW PATIENT MEDICAL HISTORY FORM -07/2010
Have you had any of the following within the last MONTH? (REVIEW OF SYSTEMS)
Fever (General) Balance problems (Neuro)
shortness of breath (Resp)
edema /Leg swelling (Cardiac) drowsiness
abdominal / stomach pain (GI)
Constipation with bowel movement muscle weakness WHERE?:___________________ Itchy skin (Skin)
lost weight without eating less
depressive symptoms/Feelings of sadness (Psych)
sleep disturbance/insomnia/ Difficulty sleeping libido decrease/low sex drive (GU) suicidal/ Thoughts of harming yourself
(MUSCULOSKELETAL)
R L Hand tingling that wakes you up at night R L Hand tingling that improves with shaking it SOCIAL HISTORY
OCCUPATION: __________ disabled homemaker office work retired unemployed NOT WORKING since ______________* STILL WORKING with…. *
Do you smoke? Yes No How many packs a day? ______________________ ALCOHOL don’t drink every day (minimal) 1-2 drinks a day (moderate) more than 3 drinks a day (heavy) less than a few times a year (seldom/rare) ANY previous illegal drug use: ____________________________________________________ G.M.O. This page has been reviewed ____________Date_________ Patient Name: ________________________________________________________ NEW PATIENT MEDICAL HISTORY FORM -07/2010
PRIOR PAIN
PAST SURGICAL HISTORY
PAST MEDICAL HISTORY
TREATMENTS/
What surgeries have you had?
What are your medical problems?
FAMILY HISTORY
What have you tried
No previous surgery
No significant medical disease
ORTHOPEDIC SURGERIES Alcoholism
PHYSICAL
ARTHROSCOPES…
MODALITIES:
INJECTION
JOINT REPLACEMENTS.
SPINE-please describe, like
FAMILY HISTORY
OTHER SURGERIES (yours)
Does your family have breast augmentation
Any of the problems
Listed below?
ANY OTHER SURGERIES?
Is there anything else we should know? ___________________________________________________ G.M.O. This page has been reviewed ____________Date_________

Source: http://greatermetroortho.com/docs/2010-07-Medical_History_Form_Hung.pdf