ORTHOPAEDIC SURGERY NEW PATIENT FORM Name (printed):___________________________________ Date of Birth: ______________ Age:________ Family Doctor:_____________________________ Referring Doctor:_______________________________ Chief complaint (reason for visit – be specific): ______________________________________________ For how long have you had your symptoms? ______days ______weeks ______months ______years Was there an accident/fall associated with it? _____________________________________________ Are you right or left-handed? (circle one) RIGHT-HANDED What kind of symptoms are you experiencing? NUMBNESS TINGLING WEAKNESS CLICKING LOCKING CATCHING GIVING WAY FALLING 2 3 LEFT-HANDED On a scale of 1-10, rate your pain 1 4 5 Describe (circle) the quality of the pain SHARP Does the pain radiate (shoot down or up)? _____________________________________________ When is it worse? MORNING NIGHT Does it wake you up from a sound sleep YES NO Does putting weight on it make it BETTER WORSE Does anything else make it worse? _____________________________________________ What type of treatments have you tried? ICE/HEAT DULL 6 7 8 9 LIKE A TOOTHACHE WITH ACTIVITY 10 (worst) BURNING AT REST SAME CRUTCHES PHYSICAL THERAPY NONE MEDICATION INJECTIONS (date of last injection) SURGERY Have you had any imaging? X-Ray CT MRI Bone Scan Other Please draw out your symptoms. Use “X” for pain and “O” for a numbness (use arrows to show shooting pain) Please sign on the top line. This information is accurate to the best of my knowledge: Patient Date I have reviewed this information with the patient: Physician FRONT BACK Date ORTHOPAEDIC SURGERY NEW PATIENT FORM MEDICAL HISTORY Have you ever had the following problems? (circle all that apply) Cancer (tumor) – What kind? Hay Fever /// Asthma Emphysema /// COPD /// Tuberculosis /// Pneumonia Unusual bleeding /// Anemia (low blood) DVT (blood clot in the leg) /// PE (blood clot in the lungs) Diabetes (sugar) Thyroid Disease Epilepsy (fits/seizures/convulsions) /// Stroke Arthritis (osteoarthritis) /// Rheumatism /// Lupus /// Gout High Blood Pressure Heart attack /// Heart failure /// Rhythm Trouble High Cholesterol Hepatitis /// Cirrhosis /// Other Liver Problems Gallstones /// Other Gallbladder Problems Stomach Problems /// Reflux (heartburn) /// Ulcers Kidney Trouble /// Bladder Trouble Anxiety /// Depression /// Other Emotional Problem Reaction To Anesthesia – What kind? Please list all surgeries you have had: Surgery Date Where Surgeon _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Please list all the medicines you are currently taking (including over the counter medicines) Drug Dose Frequency Drug Dose Frequency ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ ___________________________________________ _____________________________________________ MEDICATION ALLERGIES: Please answer the following social questions: Do you currently smoke or chew? Y N __________ packs/cans per day and for___________ years Did you ever smoke or chew? Y N When did you quit? Do you drink alcohol? Y N How often? ___________________________________ _________________________________________ What do you do for a living? Do you exercise? How often? Marital status? (circle one) Single Married Separated / Divorced Does anyone in your family have a history of (list relatives in space provided) Cancer Y N ______________________________________________ Heart Disease Y N ______________________________________________ High Cholesterol Y N ______________________________________________ Diabetes Y N ______________________________________________ Lung Disease Y N ______________________________________________ High Blood Pressure Y N ______________________________________________ Bleeding or Blood Clotting Disorder Y N ______________________________________________ Reaction to Anesthesia Y N ______________________________________________ Have you experienced any of the following within the past 6 months? (circle all that apply) Unintentional Weight Loss Frequent Fevers /// Sweats /// Chills Serious Problems with Eyes Serious Problems with Ears Difficulty Swallowing Frequent Cough /// Wheezing Shortness of Breath at Rest /// Shortness of Breath With Activity Racing Heart (palpitations) Chest Pain at Rest /// Chest Pain With Activity Frequent Constipation /// Frequent Diarrhea Frequent Rectal Bleeding /// Tar-like Stool Frequent Nausea /// Vomiting Frequent Pain or Problems Urinating Persistently Swollen Glands Skin Problems /// Skin Sores Redness of Joints /// Swelling in Joints Unusual or Persistent Back Pain Excessive Stress from Home or Work Persistent Swelling the Legs or Ankles Frequent Headaches The information provided in this form is accurate to the best of my knowledge. Patient’s Signature Date I have personally reviewed the information in this form with the patient. __________________________________________________________________________________________ Physician’s Signature Date Thank you for filling out this questionnaire. Your doctor will see you shortly.