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Home , Cuboid syndrome, Sesamoiditis

Date of Visit: ______/ ______/ ______

ID # (R=Research) +MR#

Patient Medical History Form

Name: ______:   osgood-schlatter’s Date of Birth: ______/ ______/ ______Sex: M F  dissecans Social Security ______-_____-______ chondromalacia   patella femoral syndrome Race:  African-American  Asian  Caucasian  /rupture   Hispanic  Other: ______(ACL, medial collateral)  torn meniscus other______Address:______:  femur fracture  City: ______State: ______ZIP: ______ muscle / tear  other______Primary Phone: ______- ______- ______ / Pelvis: Email: ______ arthritis  hip flexor strain  bursitis  labral tear Emergency Contact Information:  dislocation  pubis Name: ______ fracture  snapping hip  growth plate injury  stress fracture Relation: ______Phone:______ other ______Health Insurance Information: Lumbar-Sacral Spine (low back): Name of Insurance Co: ______ arthritis  sciatica Name of Policy Holder: ______ disc herniation/protrusion  scoliosis  facet syndrome  spinal stenosis Policy #: ______Group#: ______ fracture  spondylolsysis  pinched nerve  spondylolisthesis Insurance Co Phone #: ______- ______- ______ sacroiliac sprain / dysfunction Is policy holder the guarantor? Yes / No If no, name &  other ______address of person to be billed:______Cervical / Thoracic Spine ( / mid back)/Ribs: ______ arthritis  spinal stenosis  disc herniation/protrusion  spondylolisthesis Date of birth of guarantor: ______/ ______/ ______ facet syndrome  spondylolsysis Primary Healthcare Provider Information:  fracture  thoracic outlet syndrome  pinched nerve  Name: ______ scoliosis  other ______

Phone: ______Fax: ______: Address: ______ acromioclavicular  impingement sprain/separation  labral tear Orthopedic History:  arthritis  mechanical instability Check any orthopedic injury you have had and describe below.  bursitis  Circle any injury that caused you to miss a class, rehearsal, or  dislocation/subluxation  scapulo-thoracic performance > 10 days:  fracture dyskinesis  other______ tendinitis  / :  arthritis  fracture  / Wrist / Hand:  impingement  morton’s neuroma  arthritis  sprain  os trigonum  plantar  carpal tunnel syndrome  tendinitis  sesamoiditis  sprain  dislocation  torn cartilage  stress fracture  tendinitis  fracture  ulnar neuritis  other______ osteochondritis  other ______Lower Leg / Shin: (bone chip in joint)  compartment syndrome  fracture  myositis   stress fracture  other______

Give dates and explain treatments for any items checked from the above.______

Have any of the above injuries required x-rays, MRI, CT scan, injections, physical/occupational therapy, a brace, a cast, or crutches:  Yes  No If yes, please state which injuries and tests and give dates: ______

Do any of the above injuries still bother you?  Yes  No If yes, describe:______

Medical History: Check any medical conditions that you have been diagnosed with: Give dates and treatments for any of the items to the left  Anemia  Enlarged spleen checked:  Asthma  Heart murmur ______ Atlantoaxial instability  Hepatitis ______

 Concussion  Herpes or MRSA infection ______ Connective tissue/  High blood pressure rheumatologic disease  High cholesterol Which, if any, of the medical conditions are ongoing?  Depression  Kawasaki disease ______ Diabetes  Mono (infectious ______ Difficulty controlling bowel mononucleosis)  Difficulty controlling bladder  or  Easy bleeding  Numbness, tingling, or  Endocarditis/heart infection weakness in

Have you ever been hospitalized?  Yes  No If so, describe and give date(s):______Have you ever had surgery?  Yes  No If so, describe and give date(s):______Do you take any medications or supplements?  Prescription medication  Herbal supplement  Over-the-counter medication  Calcium supplements  Daily vitamin  Other If so, please list: ______

Do you have any allergies?  Medication  Stinging insects  Food  Environmental  Other If so, please list all allergies: ______

Are your vaccinations complete and up-to-date?  Yes  No

Family History:

Has anyone in your family been diagnosed with a medical condition? Give details for any items to the left checked:  Arthritis  Pacemaker/implanted ______ Diabetes defibrillator ______ Cancer  Psychological ______ Heart problem  Seizure  Hypertension  Stroke  Osteoporosis  Unexplained fainting  Other______

Has any family member died of heart problems or had an unexplained sudden death before age 50?  Yes  No

General Health: Please rate your health:  Excellent Good Fair Poor

What is your height and weight? ______Feet ______Inches ______Pounds

Do you currently smoke tobacco?  Yes  No If so, cigarettes/cigars per day?______

How many alcoholic drinks do you have per week on average (one beer/glass of wine equals one drink)? ______

Have you ever felt you need to cut down on your drinking?  Yes  No

Are you on a special diet or do you avoid certain types of foods?  Vegetarian  Vegan  Other______

Do you worry about your weight?  Yes  No

If you are not satisfied with your weight, what is your ideal weight? ______Pounds

Has anyone recommended that you gain or lose weight?  Dance teacher/director  Family member  Doctor/medical professional  Peer  No one has recommended weight change  Other______

Is your weight stable or does it often fluctuate (>10 lbs)?  Stable  Fluctuate

Have you ever had an eating disorder?  Yes  No

On a typical day, how many hours do you sleep? ______hours Do you feel that this is adequate for you?  Yes  No

Have you had any major life changes during the past year?  Yes  No

Do you feel stressed out or under a lot of pressure?  Yes  No

During the past month, have you felt down, depressed, or hopeless?  Yes  No

During the past month, have you lost interest or pleasure in doing things you usually like to do?  Yes  No

Women: Age of first menstrual period: ______Do you currently get a regular menstrual period (every 28-35 days)?  Yes  No If no, what is the time period between cycles (days)? ______Has you menstrual period always been regular?  Yes  No At what age did the irregular pattern exist? ______How long did the irregular pattern exist? ______What was the length between cycles? ______Do you use a form of birth control that gives you estrogen supplementation?  Yes  No

Within the last 6 months, have you had recurrent abdominal or discomfort ("discomfort" means an uncomfortable sensation not described as pain.)?  Yes  No If yes, during the last 3 months, has your abdominal pain or discomfort occurred at least 3 days per month?  Yes  No If yes, does this abdominal pain or discomfort improve with defecation?  Yes  No If yes, is the onset of abdominal pain or discomfort associated with a change in frequency in stool?  Yes  No If yes, is the onset of abdominal pain or discomfort associated with a change in form (appearance) of stool?  Yes  No

Dance History: Which of the following best describes you?  Choreographer  Professional-track dance student  Professional dancer  Recreational dancer  Teacher  Other______

What is your primary type of dance?  Ballet  Modern  Musical Theater  Jazz  Hip-hop  African  Tap  Ballroom  Other______

Name of Primary Dance School or Company: ______

Number of years of professional dancing? ______

At what age did you begin serious dance training? ______If pointe, at what age did you begin pointe work? ______

How many hours of class do you take in a typical week? 0 1-5 6-10 11-15 16-20 >20

How many hours do you rehearse and perform in a typical week? 0 1-5 6-10 11-15 16-20 >20

How many hours per day do you typically train en pointe? 0 1-5 6-10 11-15 16-20 >20

Do you warm up?  Never  Seldom  About half the time  Usually Always

If so, what does your warm up consist of? ______

Do you stretch?  Never  Seldom  About half the time  Usually Always

When do you stretch?  Before dance  During dance  After dance

What does your stretching program consist of?  Static (prolonged holds)  Dynamic (through movement)  Ballistic (bounding)

If you do any cardiovascular or strengthening exercise outside of your warm up on a regular basis, please describe: ______How many days per week? ______Duration per session on average (in minutes)? ______

Type of dance shoe worn most often:  None  Ballet slippers  Character shoes  Jazz oxfords  Pointe Shoes  Sneakers  Street shoes  Other______

Do you dance on sprung floor?  Never  Seldom  About half the time  Usually Always

Do you have another job to subsidize your dance life?  Yes  No If yes, how many hours do you work per week?______If yes, what are the physical demands of your job?______

Medical Complaint: What is your present injury/problem?

Part of body: ______Development of Injury: Traumatic / Acute Slow Onset

Rate your current level of pain (circle one. 0 = no pain; 10 = unbearable pain): 0 1 2 3 4 5 6 7 8 9 10

Date of injury, inability to participate in full dance, or “trigger” (the day when you decided to seek care for a slow onset injury)? (date) ______/______/______;  Morning  Afternoon Evening

If you have had this injury before, when did this injury first occur? ______

What did you do for the problem(s)? ______

Did the problem(s) get better? Yes No Today’s Date: ______FOR OFFICE USE ONLY

Patient Name: ______ID#: ______DOB: ______Sex: M/F

What was the mechanism of injury?

Inversion Eversion Hyperextension Hyperflexion Rotation Compression Valgus Varus Repetitive Stress Other_____

Body Part: Right  Left Injury Type Trunk/Back Lower Extremity Upper Extremity Acute/sub-acute (<6 wks Cervical Hip/Pelvis Shoulder Chronic (> 6wks) Thoracic Thigh Elbow Chronic Recurrent Lumbar /Sacral Knee / Post-operative Pelvis Leg Wrist/Hand Foot/Ankle ______Head

DIAGNOSIS Preliminary Final

Muscle/ Injury Internal Derangement/ Fracture/Bony Injury Ligament Injury Contusion Joint Capsule Apophysitis Sprain Mechanical LBP Sever’s Disease Grade I Capsulitis  Capsular Strain Osgood-Schlatter’s Grade II  Cuboid Syndrome  Grade III / Rupture /Bursitis Cyst Bone Spur Tissue: Achilles Ganglion Chondromalacia AC Joint Biceps brachii Meniscal D.J.D. ACL Calcific Dislocation/Subluxation Fracture Forefoot th FHL Failure Orthopedic Implant  Dancer’s (5 met) LCL Greater Trochanteric Hallux Valgus Jones Fracture Lateral Ankle  ITB Hernia Metatarsal MCL Lateral Epicondylitis HNP Stress Fracture Midfoot Medial Epicondylitis Impingement Calcaneus PCL Olecranon process Anterior Femur Syndesmosis st  Patellar Posterior Fibula 1 MTP Jt  Peroneal Joint  Metatarsal Other______ Pes Anserine Labral Tear Pelvis Psoas/Iliopsoas LMT  Spondylolysis Quadriceps Loose Bodies Talus Rotator Cuff Mechanical Instability Tibia Tibialis Anterior MMT Other_____ Tibialis Posterior Morton’s Neuroma

Other____ Patellofemoral Syndrome Hallux Limitus Misc Strain  Osteochondral injury Concussion Laceration Grade I Sciatica Os trigonum syndrome  Benign Tumor Grade II SI Joint Disorder Osteoarthritis Grade III / Rupture  Osteoporosis Tissue: Other______Periostiitis Quadriceps Scoliosis Hamstring Sesamoiditis Adductor Spondylolisthesis ITB Other Gastroc Soleus Abdominals Other______Other______

FOR OFFICE USE ONLY

Patient Name: ______ID#: ______DOB: ______Sex: M/F

PT/ATC Recommendations: Activity Modification Full Dance Activities No Dance Activities MD Referral Nutritionist Consult

Date: ______

Preliminary MD Recommendations: Modify Dance Activity Full Dance Activities No Dance Activities Surgery

Diagnostic Testing X-ray MRI/MRA Bone Scan CT Scan Lab Work Other______

Date: ______

Time Lost (Injury caused the dancer to completely stop dance Return to dance______activity, meaning class, rehearsal or performance outside of DOI itself.) Yes No

NOTES:______

MD Initial: ______