GEORGE WASHINGTON UNIVERSITY SPORTS MEDICINE
NEW PATIENT QUESTIONNAIRE
RAJEEV PANDARINATH, MD
Name: _______________________________ Gender: ____ Male ____ Female Date of Birth: ____/____/____
Telephone Number: Home: _________________ Work: ___________________ Cell Phone: _________________
Primary Care Physician: ______________________________________ Phone Number: ______________________
Address:__________________________________________________________________________________
Referring Physician/ Work Comp Agency/ Nurse/ Trainer/ Therapist (circle one):
Name: _______________________________________________ Phone Number: ______________________
Address: _________________________________________________________
Age:______ Height: ____ ft. ____ in. Weight: _______lbs. Heart Rate: ______ Hand Dominance: ___ R ___L
Occupation: ___________________________________ Auto/Worker’s Compensation Case: _____ Yes _____ No
What leisure activities/sport(s), if any, do you participate in? ___________________________________________
Location of Symptoms: _____ Right _____ Left _____ Both
____ Head
____ Neck
____ Shoulder
____ Arm
____ Elbow
____ Forearm
____ Wrist
____ Hand
____ Mid-Back (thoracic)
____ Low-Back (lumbar)
____ Hip
____ Thigh
____ Knee
____ Shin/Calf
____ Ankle
____ Foot
Please Mark Location of Symptoms on Figures(s) Below:
Front
Back
Date of Injury (if known): _____/_____/_____
Duration of Symptoms: _____ Day(s) _____Week(s) _____Month(s) _____ Year(s)
How Injured:
_____ Trauma _____ Motor vehicle/Motorcycle accident
_____ Sports _____ No Injury
_____ Fall
_____ Other:_______________________
Mechanism of Injury:
_____ Chronic overuse
_____ Sudden stop
_____ Throwing
Symptoms:
_____ Swelling
_____ Locking
_____ Catching
_____ Clicking
_____ Giving way
_____ Stiffness
_____ Fevers/Chills
_____ Twist/Pivot
_____ Direct impact
_____ Reaching
_____ Weakness
_____ Numbness
_____ Tingling
_____ Burning
_____ Partial dislocation
_____ Dislocation
_____ Symptoms in morning
Pain Level: __ Mild __ Moderate __ Severe
Where injured:
_____ Work
_____ Sporting event
_____ Home _____ Gym
_____ Other:____________________________
_____ Lifting
_____Fall
_____ Running
_____ Jumping
_____ Bending
_____ Don’t recall
_____ Other:____________________________________
_____ Symptoms during day
_____ Symptoms in evening
_____ Symptoms at sleep
_____ Symptoms at rest
_____ Symptoms with activity
_____ Symptoms with reaching
_____ Symptoms with stairs
_____ Symptoms with squat/kneel
_____ Symptoms with sitting
_____ Symptoms with walk/run
_____ Symptoms with throwing
What makes the symptoms worse? ________________________________________________________________
______________________________________________________________________________________________
What makes the symptoms better? ________________________________________________________________
______________________________________________________________________________________________
Prior history of surgery or treatment for this specific problem? ____ Yes ____ No
If "YES" please check all that apply:
____ Physical/Occupational Therapy (Duration: _____ Weeks _____ Months)
Improved condition: _____ Yes _____ No
Worsened condition: _____ Yes _____ No
____ Injection(s)
Type: _____ Joint _____ Soft tissue _____ Trigger point _____ Epidural
Medication used: _____ Steroid _____ Joint fluid (ie. Synvisc, Supartz, Hyalgan, Orthovisc, Euflexxa)
Total number of injections given: _________ (Date of most recent injection: ____/_____/_____)
Improved condition: _____ Yes _____ No
Worsened condition: _____ Yes _____ No
____ Medications used: _____________________________________________________________________
____ Surgery
Procedure: ___________________________________________________ Date: ____/____/____
Surgeon: _________________________________________________________________________
Any complications during or after? _____________________________________________________
Procedure: ___________________________________________________ Date: ____/____/____
Surgeon: _________________________________________________________________________
Any complications during or after? _____________________________________________________
____ Chiropractic
____ Accupuncture
____ Foot Orthotics
____ Casting (How many weeks were you casted? _______ weeks)
____ Brace (Type: ________________________________________________ )
____ Other (please specify): _________________________________________
Have you had any studies done to evaluate this problems? _____ Yes _____ No
Date(s)
Location
____X-rays __________________________
________________________________________________
____MRI ____________________________
________________________________________________
____Cat Scan ________________________
________________________________________________
____Ultrasound _______________________ ________________________________________________
____ Bone Scan ______________________
________________________________________________
____ EMG/NCS ______________________
________________________________________________
MEDICAL/SURGICAL HISTORY:
Medical problems you currently have OR have had in the past (Check all that apply):
____ High blood pressure
____ Asthma
____ Osteoarthritis
____ Kidney disease
____ Heart attack
____ COPD
____ Rheumatoid arthritis
____ Urinary problems
____ Heart failure
____ Sleep Apnea
____ Gout
____ Bleeding disorder
____ High cholesterol
____ Diabetes
____ Systemic lupus
____ Anemia
____ Irregular heart beat
____ Thyroid disease
____ Lyme disease
____ TB
____ Pacemaker/Defib.
____ Osteopenia,-porosis
____ Fibromyalgia
____ HIV
____ Vascular disease
____ Migraines
____ Stress fractures
____ Depression
____ Clots
____ Seizures
____ Hepatitis
____ Glaucoma
____ Aneurysm
____ Concussion
____ Gastric reflux/ulcer
____ Hearing loss
____ Stroke
____ Alzheimers
____ Irritable bowel
____ ADHD
____ Cancer (Type(s): _____________________________________________________________________________
Please list any surgical procedures (for any reason) you have had in the past:
Month/Year
Surgery Type
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
ALLERGIES to any medications? _______ Yes _______ No
If "YES", please list: _____________________________________________________________________
MEDICATIONS/VITAMINS/DIETARY SUPPLEMENTS you are currently taking?
_____________________________________________________________________________________
_____________________________________________________________________________________
SOCIAL HISTORY:
Do you smoke? ____ Yes ____ No If "YES", how many packs per day? ________
Do you drink alcohol? ____ Yes ____ No
If “YES”, is you weekly intake: ____ Light ____ Moderate ____ Heavy ____ Social drinker only
Are you currently working? ____ Yes ____ No ____ Disabled ____ Student
If "YES", what is your current occupation? __________________________________________________
Your current work day is: ____ Full Time ____ Part Time
What is your current work status: ____ Full Duty ____ Modified Duty with Restrictions
Are you married? ____ Yes ____ No ____ Divorced/Separated
How many children do you have? _______
_____ Widowed
What leisure activities/sports do you regularly participate in?: _______________________________
FAMILY HISTORY (including parents, grandparents, and siblings):
Illness
Which Family Member(s)?
Cancer
____ Yes ____ No ________________________________________
High blood pressure
____ Yes ____ No ________________________________________
Heart disease
____ Yes ____ No ________________________________________
Asthma/COPD
____ Yes ____ No ________________________________________
Diabetes
____ Yes ____ No ________________________________________
Thyroid disease
____ Yes ____ No ________________________________________
Strokes
____ Yes ____ No ________________________________________
Mental illness
____ Yes ____ No ________________________________________
Bleeding disease
____ Yes ____ No ________________________________________
Rheumatoid arthritis
____ Yes ____ No ________________________________________
Osteoarthritis
____ Yes ____ No ________________________________________
Systemic lupus
____ Yes ____ No ________________________________________
Other: __________________________________________________________________________
REVIEW OF SYSTEMS
(Please check all current medical issues):
YES NO
____ ____ Decreased hearing
____ ____ Ringing in ear
____ ____ Ear infections
____ ____ Dizzy spells
____ ____ Fainting spells
____ ____ Double vision
____ ____ Blurred vision
____ ____ Nosebleeds
____ ____ Sinus trouble
____ ____ Sore Throats
____ ____ Hay fever/allergies
____ ____ Shortness of breath
____ ____ Chest pain
____ ____ Heart palpitations
____ ____ Leg pain when walking
____ ____ Tremors/ hands shaking
____ ____ Muscle weakness
____ ____ Headaches
____ ____ Foot pain
____ ____ Rash
____ ____ Eczema
____ ____ Insomnia
YES
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
____
NO
____ Loss of appetite
____ Difficulty swallowing
____ Heartburn
____ Nausea/vomiting
____ Chronic abdominal pain
____ Change in bowel habits
____ Constipation/diarrhea
____ Bloody/tarry stools
____ Urinary problems
____ Urethral discharge
____ Chronic fatigue
____ Weight change
____ Gain
____ Loss
____ Numbness/tingling
____ Back pain
____ Cold/numb feet
____ Hives
____ Memory loss
____ Difficulty concentrating
____ Anxiety
____ Nervousness
By signing below, I verify that the above information is correct and true to the best of my knowledge.
__________________________________
(Patient Name)
__________________________________
(Patient Signature)
_____________ (Date)