Suffolk Orthopaedic Associates, P.C.
INITIAL VISIT
375 East Main Street, Suite #1, Bay Shore, NY 11706 (631) 665-8790
TODAY’S DATE:
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?
IF SO WHAT IS THE DATE OF THE ACCIDENT?
IF SO WHAT IS THE DATE OF THE ACCIDENT?
IF APPLICABLE, PLEASE GIVE DETAILS OF ACCIDENT / INCIDENT
IS THERE ANY TIME WHEN PAIN IS WORSE?
MORNING
AFTERNOON
WHAT DESCRIBES THE PAIN THAT YOU USUALLY FEEL (PLEASE CIRCLE):
Burning
Ache
Pins & Needles
Tingling
Constant
Dull
Sharp
Shooting/Radiating
Numbness
Spasm
Increased pain to touch
Other:
EVENING
Intermittent
ANY OTHER ASSOCIATED PROBLEMS? (INCLUDING SWELLING, WARMTH TO TOUCH, DECREASED
MOTION)______________________________________________________________________
ANY FACTORS THAT MAKE THE PAIN WORSE?
ANY FACTORS THAT MAKE THE PAIN BETTER?
ARE YOU EXPERIENCING ANY OF THE FOLLOWING? (PLEASE CIRCLE)
Weight loss
Fever
Weakness
Headache
Problems walking
Bowel problems
Bladder problems
Sexual Dysfunction
WHAT ARE YOUR GOALS/EXPECTATIONS OF TREATMENT?
WHAT TREATMENTS / TESTS HAVE YOU ALREADY DONE FOR THIS PROBLEM? (PLEASE CIRCLE)
Physical Therapy?
Medications?
Surgery?
XRAY / MRI / Cat Scan?
CURRENT MEDICATIONS (PLEASE INCLUDE DOSAGES)
ALLERGIES TO ANY OF THE FOLLOWING? (PLEASE CIRCLE)
Anti-inflammatory Meds / NSAIDS / Aspirin
Antibiotics / Penicillin / Sulfonamides
Iodine / Dye
Steroids / Lidocaine / Anesthesia
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:
FAMILY HISTORY (PLEASE LIST ANY MEDICAL ILLNESSES IN YOUR FAMILY)
Mother:
Father:
Siblings:
SOCIAL HISTORY:
Have you ever used illicit / recreational drugs?
Do you smoke? (please circle) NEVER
QUIT CURRENTLY SMOKE
Alcohol use? (please circle)
NEVER
SOMETIMES OFTEN
Do you currently work?
Current job:
Does you job involve lifting or bending?
Are you on disability?
Are you currently working?
PLEASE CIRCLE: MARRIED SINGLE DIVORCED OTHER:
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
Do you feel you are currently depressed?
Do you have issues with anxiety?
Do you have problems with sleep?
Do you exercise?
Are you currently trying to lose weight?
Is there any chance that you are pregnant?
Do you have any metal device implanted in your body?
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