PATIENT NAME: ______________________________________
NEW PATIENT MEDICAL HISTORY
AGE:
Occupation:
___________________________
___________________________
CHIEF COMPLAINT: (WHAT IS THE REASON FOR YOUR VISIT TODAY?)
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
HISTORY OF PRESENT ILLNESS:
LOCATION: (WHERE IS THE PROBLEMLOCATED?)________________________________________________________
DURATION: (HOW LONG HAVE YOU HAD THE PROBLEM?) _______________________________________________________
CONTEXT: (HOW DID YOUR PROBLEM START?)_____________________________________________________________________
TIMING: (DO YOU HAVE PAIN?) No Yes
IF YES, IS THE PAIN CONSTANT (HURTS ALL THE TIME) OR
INTERMITTENT (COMES AND GOES)?
QUALITY: (DESCRIBE YOUR PAIN BY CHECKING ALL THAT APPLY BELOW)
ACHING
BURNING
THROBBING
STABBING
SHOOTING
LOCKING
CLICKING
CATCHING
TENDER
INSTABILITY
BACK PAIN LEG/FOOT NUMBNESS
LEG/FOOT PINS AND NEEDLES
SHARP
WEAK
CRAMPING
SIGNS/SYMPTOMS:DESCRIBE ANY SPECIFICSIGNS OR SYMPTOMS
_____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
WHAT MAKES YOUR PROBLEM BETTER? ______________________________________________________________
ICE
ACTIVITY CESSATION BRACE REST
NSAID’S (IBUPROFEN, NAPROXEN, CELEBREX, ETC.)
WHAT MAKES YOUR PROBLEM WORSE? ______________________________________________________________
WALKINGUP/DOWN STAIRS SQUATTING PIVOTING RUNNING
ALLERGIES: (LIST ALL KNOWN ALLERGIES AND REACTIONS)
 NO KNOWN ALLERGIES
 LATEX / RUBBER
 TAPE
 FOOD (LIST):
 IODINE
CIRCLE THE NUMBER THAT BEST
DESCRIBES YOUR CURRENT PAIN LEVEL .
______________________________________________________________________________________
 MEDICATIONS (LIST):
______________________________________________________________________________________
 OTHER: (LIST):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
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PATIENT NAME: ______________________________________
PAST MEDICAL & SURGICAL HISTORY
PAST MEDICAL HISTORY
TAKING MEDICATIONS FOR THE PROBLEM
CURRENT MEDICAL PROBLEMS
YES
NO
COMMENTS
SURGICAL HISTORY
COMPLICATIONS
PAST SURGICAL HISTORY (ORTHOPAEDIC)
YES
NO
COMMENTS
SURGICAL HISTORY
COMPLICATIONS
PAST SURGICAL HISTORY
FAMILY HISTORY
YES
NO
COMMENTS
FAMILY & SOCIAL HISTORY
YES NO
WHICH RELATIVE OR ANY PERTINENT COMMENTS
Cancer
Diabetes
Type I: _____ Type II: ____
Heart Disease
Hypertension
Kidney Disease
Lung Disease
Mental Illness
Seizures
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PATIENT NAME: ______________________________________
Stroke
Thyroid Problems
Tuberculosis
SOCIAL HISTORY
Substance Abuse
 NO
 YES | DESCRIBE:
Alcohol Use:
 NEVER  RARELY  MODERATE  DAILY
Tobacco Use:
 NEVER  FORMER  LESS THAN 1 PACK PER DAY  GREATER THAN 1 PACK PER DAY | YEARS:
Smokeless Tobacco:  NEVER  RARELY  MODERATE  DAILY
Caffeine Use:
 NEVER  PREVIOUSLY  CURRENTLY | TYPE / FREQUENCY:
Illicit Drug Use:
 NEVER  PREVIOUSLY  CURRENTLY | TYPE / FREQUENCY:
Occupation:
Marital Status
 SINGLE  MARRIED  SEPARATED  DIVORCED  WIDOWED  OTHER:
Children
 NO
 YES | IF YES, HOW MANY:
Cultural, Religious or Language Concerns that may affect your care:
Do family and friends provide help when needed?  NO  YES
Transportation Concerns (able to drive, etc.)?:
Able to Care for Self (dressing, bathing, etc.)?  NO  YES If “No”, explain :
Do you currently have Home Care or Hospice?  NO  YES If “Yes”, explain :
ADVANCED DIRECTIVES & INSTRUCTIONS: (CHECK ALL THAT APPLY)
 I HAVE AN ADVANCE DIRECTIVE
 I HAVE A LIVING WILL
 I HAVE A DURABLE POWER OF ATTORNEY FOR HEALTHCARE
 ADVANCE DIRECTIVE MATERIALS WERE PROVIDED TO ME
 I HAVE A COPY OF MY LIVING WILL FOR THE HOSPITAL
 I DO NOT WANT TO BE RESUSCITATED
MEDICATIONS - - WRITE ON BACK IF MORE ROOM NEEDED
[PLEASE LIST ALL MEDICINES YOU ARE CURRENTLY TAKING - - INCLUDE OVER THE COUNTER, HERBAL & VITAMIN SUPPLEMENTS]
MEDICATIONS
AMOUNT / DOSAGE
HOW OFTEN
GENERAL NOTES
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Bay Area Bone & Joint Center
PATIENT NAME: ______________________________________
PATIENT SIGNATURE: _________________________________________
DATE: _______________ TIME: __________
(OR LEGAL GUARDIAN/POA)
I HAVE REVIEWED THE NEW PATIENT MEDICAL HISTORY WITH THE PATIENT / CAREGIVER AS PART OF THE INITIAL NURSING ASSESSMENT.
NURSE SIGNATURE: ___________________________________________
DATE: _______________ TIME: __________
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Bay Area Bone & Joint Center