New Patient Questionnaire s1

Patient History

Patient Name: ______Today’s Date: ______Age: ______Height: ______Weight: ______Hand Dominance: Right Left Family Physician: ______Phone: ______Referring Physician: ______Phone: ______

History of the Present Illness or Injury (Why are you here today?) Injury to: Left Right Both Arm Shoulder Elbow Wrist Hand Lower Leg Leg Ankle Foot Hip Upper leg Knee Other: ______

Did your problems result from a specific injury? Yes No If yes, Injury/Accident Date: ______If yes, was the injury related to: Work Injury Motor Vehicle Accident How did you get injured? ______If no injury, how long have you had the condition? ______Tobacco Use: Packs per day: ______Years Smoked: ______Date quit: ______Alcohol Use: Drinks per week (include beer as one beer =one drink): ______What, if anything, makes your symptoms better? ______What, if anything, makes your symptoms worse? ______Is your pain getting: Worse? Same? Better? Have you seen another physician for this injury or condition? Yes No If yes, who? ______

What treatments have you tried? Physical Therapy Exercise Rest Other Ambulatory Aid Topical Cream Brace

Have you had any of the following tests? X-rays MRI Scan CT Scan EMG/NCV Discogram Blood Tests Other

Have you had any injections? Updated: 2/24/2015 If yes, where they: Steroid Viscosupplement (i.e. Synvisc, etc.)

PATIENT HISTORY

Patient Name: ______

Medical History: (YOU / FAMILY) ____ / ____Anemia ____ / ____Colon Cancer ____ / ____Kidney Disease ____ / ____Arthritis ____ / ____Diabetes ____ / ____Kidney Failure ____ / ____Anxiety ____ / ____Depression ____ / ____Leg Cramps ____ / ____Asthma ____ / ____Diabetic Foot Ulcer ____ / ____Lung Disease ____ / ____Alcoholism ____ / ____Emphysema ____ / ____Liver Problems ____ / ____Anesthetic Complication ____ / ____Heart Attack ____ / ____Lupus ____ / ____ Birth Defect ____ / ____Hepatitis A ____ / ____Migraines ____ / ____Bleeding Disease ____ / ____Hepatitis B ____ / ____Murmur ____ / ____Bleeding Disorder ____ / ____Hepatitis C ____ / ____Neurological Disorder ____ / ____Blood Clot ____ / ____High Blood Pressure ____ / ____Numbness/Tingling ____ / ____Breast Cancer ____ / ____HIV ____ / ____Osteoporosis ____ / ____Cancer ____ / ____Hypertension ____ / ____Pulmonary Embolism ____ / ____Chronic Back Pain ____ / ____Hypothyroidism ____ / ____Phelibitis ____ / ____Congestive Heart Failure ____ / ____Irregular Heartbeat ____ / ____Pneumatic Fever ____ / ____Poor Circulation ____ / ____Rheumatoid Arthritis ____ / ____Seizure ____ / ____Sever Allergies ____ / ____Stomach Ulcer ____ / ____Stroke ____ / ____Thyroid Problems ____ / ____Varicose Veins

Are you currently pregnant: Yes No Due Date: ______Allergies: None Metals Latex Allergy Allergy to adhesive tape

Please list any allergies that you have to any medication if applicable ______

Updated: 2/24/2015 PATIENT HISTORY

Patient Name: ______

Medications: Please list all medication you are currently taking. Include over the counter medications and dietary supplements. Medication Dosage Frequency

Past Surgical History: Please list all previous surgical procedures as well as the date and specific extremity if applicable Surgical Procedure Side Date of Procedure

Updated: 2/24/2015