What Is the Problem You Are Here For?

Felasfa M. Wodajo, MD Musculoskeletal Tumor Surgery

New Patient Questionnaire

Thank you for filling out this information that will help us take better care of you.

Today’s date:

Date of birth:

What is the problem you are here for? When did it start? If possible, please give us a history of this problem. List any treatments you have had for this problem? (Examples: physical therapy, pain clinic, chiropractor, medicine for symptoms, surgery, chemotherapy, or radiation).

Write a yes beside any imaging tests you had for this problem? X-ray date (month/year) CT date (month/year) MRI date (month/year) Bone scan date (month/year) Other:

List any medicines, vitamins, or herbal supplements that you take now.

Allergies? Do you have a latex allergy?

Do you smoke cigarettes now or ever smoked? If yes, how many per day? and for how many years?

Do you drink alcohol? If yes, how many drinks in one week?

1 Your occupation:

Has anyone in your family had a cancer diagnosis? If yes, list the family member and what type of cancer.

List any previous surgeries and dates:

Write yes beside any medical conditions you have had:

Anemia Elevated Cholesterol Osteoarthritis Angina/Cardiac Arrhythmias Fibromyalgia Osteomyelitis Asthma GERD (reflux) Osteoporosis Bleeding disorder Glaucoma Peripheral Vascular Disease Blood clots Gout Phlebitis Blood transfusion Heart murmur Psychiatric conditions BPH/Prostate disease HIV Rheumatoid Arthritis Bronchitis Hypertension (high blood Seizures Cancer pressure) Sleep apnea COPD Intestinal disease: Stomach Ulcers Coronary Artery Disease (Crohn’s/IBS) Thyroid Disease Dementia/Alzheimer’s Kidney/Renal disease Tuberculosis Depression Liver disease/Hepatitis Other: Diabetes Obesity

Your height: Your weight:

2 Write yes beside any problem you have had in the last six months:

General: Heart/circulation: Musculoskeletal: Weight loss (unplanned) High blood pressure Bone fracture Weight loss (planned) Irregular heart beat Bone pain Fatigue Palpitations Joint pain Weakness Chest pain Leg cramps Loss of coordination Swelling/edema Other muscle pain Muscle spasms Skin: Digestion/bowel habits: Numbness Ulcers Diarrhea Chronic pain Hives Trouble swallowing Loss of function Rashes Abdominal pain Nausea Nervous system: Head, eyes, ears, nose, Vomiting Seizures throat: Heartburn Fainting Headaches/Migraine Constipation Disoriented Vertigo/Dizziness Depression Vision changes Urinary system/genitals: Memory loss Hearing loss Burning when urinating Anxiety Ringing in ears Difficulty urinating Tremors Sore throat or hoarseness Bleeding with urination Incontinence (leaking urine) Lungs/breathing: Chest pain Wheezing Sleep apnea Chronic cough Shortness of breath

Thank you!

Please sign this form: