FREDERICKSBURG ORTHOPAEDIC ASSOCIATES, P.C.
DR. JOHN KETZ
PATIENT QUESTIONNAIRE
Date: ____________________________________
Patient Name: ___________________________________________________ (Office Use Only) MR # __________________
Family / Primary Doctor:__________________________________________ Phone: ________________________________
Family / Primary Doctor’s Address:
________________________________________________________________________________________________________
Who referred you to Dr. Ketz: (name & address please)
________________________________________________________________________________________________________
Date of injury: ________________________
Were you in an auto accident?
Yes
No
Is this a work-related injury covered by Workmen’s Compensation Claim?
Yes
No
Are you currently working?
Yes
No
Briefly describe your pain: ________________________________________________________________________________
________________________________________________________________________________________________________
INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Check the word or phrase that best
describes your situation. You may select more than one answer per question. Answer the question in as much detail as
possible. Write additional information in the margins if necessary. The information you provide will help the doctor to more
accurately understand your problem(s) and develop an appropriate plan of treatment for your care. THANK YOU.
Sex:_____
Age:_____
Marital Status:_____________
Check anything below to which you are allergic:
No known allergies
Penicillin
Tetracycline
Sulfa
Morphine
Erythromycin
Ht:______
Wt:______
Handed:
Right
Left
Codeine
Iodine / Betadine
Radiographic Dyes
Adhesive Tape
Other (Specify): _____________________________
Check any of the medical problems that you have had. Indicate if the problem is current (even if it is being treated) or
resolved:
I have no known medical problems
Tuberculosis
Hypertension
Liver disease
Coronary heart disease
Seizure disorder
Peripheral vascular disease
Emphysema
Adult onset diabetes
COPD / Lung problem
Childhood onset diabetes
Thyroid disease
Past heart attack
Immune disorder
Asthma
Overweight
Ulcers
Osteomyelitis
Hepatitis A/B/C
Arthritis (where?) ____________________________
Cancer
Other (specify): ______________________________
Blood Clot (DVT)
___________________________________________
FORM #BP49935-1
How much alcohol do you consume?
I’m a non-drinker
I’m a recovering alcoholic
I drink only occasionally
I drink weekends only
An average of 1-2 drinks per day
An average of 2-3 drinks per day
An average of 3-5 drinks per day
More than 6 drinks a day
Do you smoke?
Yes, I am currently a smoker. I smoke (check one)
I have smoked for __________ years.
No, but I used to smoke. I smoked for ________ years
No, I have never smoked.
Do you now, or have you ever used drugs?
Recreational
Cocaine
1
2
3 packs/day
1
2
3 packs/day.
Marijuana
Other (specify): ______________________________
Has anyone in your immediate family (mother, father, sister, brother, children) ever had any of the following? Check all
that apply.
None known
Hypothyroidism
Cancer
Colitis
Leukemia
Bleeding tendency
Stroke
Asthma
Hypertension
Tuberculosis
Coronary artery disease
Seizure disorder
Rheumatic fever
Alcoholism
Diabetes
Other (specify): ______________________________
Have you ever had a blood clot?
Yes
No
Check any surgeries listed below you may have had. Indicate the year of the surgery.
No previous surgeries
Mastectomy__________________________________
Appendectomy______________________________
Tonsillectomy ________________________________
Cataract extraction ___________________________
Prostate surgery _______________________________
By-pass / open heart __________________________
Other (specify): _______________________________
Gall bladder_________________________________
Other (specify): _______________________________
Hernia repair________________________________
Other (specify): _______________________________
Hysterectomy _______________________________
Other (specify): _______________________________
Lumbar laminectomy _________________________
Other (specify): _______________________________
REVIEW OF SYSTEMS
Have you recently experienced any of the following?
General:
Weight gain
Weight Loss
Fever
Chills
Night sweats
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Skin:
Change in moles
Breast lumps
Yes
Yes
No
No
Eyes:
Loss of vision
Double vision
Yes
Yes
No
No
FORM #BP49935-2
GI:
Nausea
Vomiting
Change in bowel habits
Heartburn
Yes
Yes
Yes
Yes
No
No
No
No
Respiratory:
Shortness of breath
Coughing/wheezing
Yes
Yes
No
No
Heart:
Chest pain
Palpitations
Fainting
Yes
Yes
Yes
No
No
No
ENT:
Hearing loss
Nose bleeds
Yes
Yes
No
No
Musculoskeletal:
Muscular weakness
Stiffness
Joint pain
Yes
Yes
Yes
No
No
No
GU:
Frequent urination
Difficulty in urination
Blood in urine
Yes
Yes
Yes
Vascular:
Swelling lower extremities
Emboli (blood clots)
No
No
No
Yes
Yes
No
No
What medications are you currently taking? Please include any vitamins, tonics, muscle relaxants, anti-inflammatories, pain
relievers, nerve medications and sleeping pills you are taking, both prescription and non-prescrip
Medications
_______________________________________________
Dose
_________________________
# Times a Day
_______________________
_______________________________________________
_________________________
_______________________
_______________________________________________
_________________________
_______________________
_______________________________________________
_________________________
_______________________
_______________________________________________
_________________________
_______________________
_______________________________________________
_________________________
_______________________
_______________________________________________
_________________________
_______________________
_______________________________________________
_________________________
_______________________
_______________________________________________
_________________________
_______________________
_______________________________________________
_________________________
_______________________
TELL US ABOUT YOUR HEALTH IN GENERAL: Do you have any of the following?
SYMPTOMS
Chest pain
Dizziness
Dry cough
Productive cough
Difficulty breathing
Irregular heartbeat
Swelling in the legs
Lack of appetite
Nausea
Vomiting
Diarrhea
Constipation
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
SYMPTOMS
Abdominal cramping
Varicose veins
Bruising
Bleeding
Nose bleeds
Joint pain and/or stiffness
Muscle pain or muscle cramps
Difficulty seeing
Difficulty hearing
Difficulty swallowing
Difficulty sleeping
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
What is your occupation?
Student
Housewife
Retired (from what occupation?)______________________________________ Since when?____________________
Employed
Full Time
Part time as __________________________________________________________
Currently an unemployed ____________________________________________________________________________
On
Permanent
Partial disability since (date) _____________________ due to _________________________
FORM #BP49935-3
Do You Live:
Alone
With family
With friends
The doctor will discuss your current problem in detail. The following questions are intended to give an overview of how it
is affecting you now. Please select the best choice for each item.
Do you have pain:
None
Mild, occasional
Moderate, daily
Severe, almost always present
What is your activity level?
No limitations, no support
No limitation of daily activities, limitation of recreational activities, no support
Limited daily and recreational activities, cane
Sever limitation of daily and recreational activities, walker, crutches, wheelchair,
Brace
Footwear requirements:
Fashionable, conventional shoes, no insert required
Comfort footwear and/or shoe insert
Modified shoes or brace
Maximum walking distance:
Greater than 6 blocks
4-6 blocks
1-3 blocks
Less than 1 block
Walking surfaces:
No difficulty on any surface
Some difficulty on uneven terrain, stairs, includes, ladders
Severe difficulty on uneven terrain, stairs, includes, ladders
Everything I have answered is true and correct to the best of my knowledge.
______________________________________________________________________________________________________
(Patient Signature)
THANK YOU FOR COMPLETING THIS PATIENT QUESTIONNAIRE.
IT WILL BECOME A PART OF YOUR PERMANENT MEDICAL RECORDS AT FREDERICKSBURG ORTHOPAEDIC
ASSOCIATES, P.C. AND WILL PLAY AN IMPORTANT PART IN UNDERSTANDING YOUR CURRENT SITUATION
AND FOLLOWING YOU IN THE FUTURE.
FORM #BP49935-4