Department of Orthopaedic Surgery

Department of Orthopaedic Surgery David Edelstein, M.D. 1301 57th Street, Brooklyn, NY 11219

MEDICAL HISTORY: Today’s Date: ______/______/2011

Name:______Age:______Date of Birth:______Address:______Telephone:______Email Address: ______Occupation:______Height: ______Weight: ______Are your right- or left-handed (circle one)? Right Left What hurts?______What side?______When did the problem start?______Type of pain (circle all that apply): dull sharp burning constant radiating What makes the pain better?______What makes the pain worse?______Rate your pain from 1-10: slight 1—2—3—4—5—6—7—8—9—10 very bad Does the pain wake you up at night? Yes  No  Have you had this problem in the past? Yes  No  Have you received any treatment for this problem? Yes  No  Condition Yes No Results Heart Disease Diabetes Asthma High Blood Pressure Hepatitis Liver Disease Kidney Disease Rheumatoid Arthritis Glaucoma Seizures or Epilepsy AIDS Anemia or Blood Disorder Are you pregnant? OTHER:

Do you have family history of arthritis, diabetes,  cancer,  other______ none  List all medications you currently take:______Allergies to medications:______List all previous surgeries:______Cigarettes per day: ______Alcoholic drinks per day: ______