Suffolk Orthopaedic Associates, P.C.
INITIAL VISIT
TODAY’S DATE:
375 East Main Street, Suite #1, Bay Shore, NY 11706 (631) 665-8790
NAME:
PHONE: BEST DAY NUMBER:
BEST EVENING NUMBER:
EMERGENCY CONTACT NAME:
NUMBER:
WHO REFERRED YOU HERE?
WHAT IS YOUR CHIEF COMPLAINT / WHERE IS THE LOCATION OF YOUR PAIN?
ANY ACCIDENT OR TRAUMA?
IS THIS A COMPENSATION CASE?
IS THIS A NO-FAULT CASE?
DATE OF ACCIDENT?
DATE OF ACCIDENT?
IF APPLICABLE, PLEASE GIVE DETAILS OF ACCIDENT / INCIDENT_________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
IS THERE ANY TIME WHEN PAIN IS WORSE?
MORNING
AFTERNOON
EVENING
WHAT DESCRIBES THE PAIN THAT YOU USUALLY FEEL (PLEASE CIRCLE):
Burning Dull Ache Pins & Needles Tingling Shooting/Radiating Numbness Spasm
Sharp Constant
Intermittent
Increased pain to touch Warmth to touch Other:
ANY FACTORS THAT MAKE THE PAIN WORSE?
BETTER?
ARE YOU EXPERIENCING ANY OF THE FOLLOWING? (PLEASE CIRCLE) Weight loss Fever Weakness
Headaches Problems walking Bowel problems/Bladder problems Sexual Dysfunction Swelling
CURRENT MEDICATIONS (PLEASE INCLUDE DOSAGES)_________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ALLERGIES TO ANY OF THE FOLLOWING? (PLEASE CIRCLE) Anti-inflammatories /NSAIDS/Aspirin/Anesthesia
Antibiotics / Penicillin / Sulfonamides / Iodine / Dye / Steroids / Lidocaine / Muscle relaxants Other:
PAST MEDICAL HISTORY (PLEASE CIRCLE IF YOU HAVE A HISTORY OF THE FOLLOWING)
Cancer Diabetes Vascular Disease Heart Disease Liver Disease Kidney Disease Hypertension
Stomach problems Arthritis Bleeding problems Other:
PAST SURGERIES/HOSPITALIZATIONS:______________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
SOCIAL / WORK HISTORY: (please circle)
Have you ever used illicit / recreational drugs? Yes/No If so, are you using currently? Yes/No
Do you smoke? NEVER QUIT CURRENTLY SMOKE
Alcohol use? NEVER SOMETIMES OFTEN
Are you currently working? Yes/No Are you on disability? Yes/No Current job:
Does your job involved lifting/bending? Yes/No Are you: MARRIED SINGLE DIVORCED OTHER:
PLEASE ANSWER YES OR NO TO THE FOLLOWING: Do you feel depressed?
Do you have issues with anxiety?
Problems sleeping?
Are you trying to lose weight?
Any chance that you are pregnant?
Do you have any metal device implanted in your body?
WHAT TREATMENTS / TESTS HAVE YOU ALREADY DONE FOR THIS PROBLEM? (PLEASE CIRCLE)
Physical Therapy? Medications?
XRAY / MRI / Cat Scan? Injections/Epidurals Surgery?
SHADE IN THE LOCATION OF YOUR PAIN