<p> Orthopaedic Specialists</p><p>Date:______</p><p>Name: ______Age: ______Date of Birth: ______</p><p>Preferred name to be called: ______Height: ______Weight: ______</p><p>Who referred you: ______</p><p>Primary Care Physician:______</p><p>CURRENT CONDITION: Current Orthopaedic Complaint:______Elbow Knee Shoulder Wrist Ankle Hip Other R L R L R L R L R L R L R L </p><p>Are you right or left handed? ______</p><p>Date of onset of injury/problem: ______</p><p>Is your injury/problem related to: auto accident _____ work related accident _____</p><p>SOCIAL HISTORY: Single_____ Married _____ Partnered _____ Separated _____ Divorced _____ Widowed _____</p><p>Occupation: ______Are you working now? Yes No </p><p>What type of exercise / sports do you participate in? ______</p><p>Current Smoker: How many packs/day? ______Number of years: ______</p><p>Former Smoker: _____ Never a Smoker: ______</p><p>Do you drink alcohol? Yes No How much and how often? ______</p><p>History of substance abuse? Yes No If yes, please describe: ______</p><p>Is there any possibility that you are pregnant? Yes No (If yes, please inform staff prior to x-rays.) ALLERGIES TO MEDICATIONS:______Reaction: ______FAMILY HISTORY: Cancer: type ______Yes No Diabetes I: Yes No Diabetes II: Yes No Heart Disease: Yes No Hypertension: Yes No High Cholesterol: Yes No Thyroid Disease: Yes No</p><p>Continued on Second Page MEDICAL CONDITIONS Do you currently have or have you ever had any of the following conditions? Condition Condition HEART DISEASE/CHEST PAIN Yes No ASTHMA/SHORTNESS OF BREATH Yes No HEART VALVE PROBLEMS/MURMUR Yes No PNEUMONIA/BRONCHITIS Yes No HIGH BLOOD PRESSURE Yes No TUBERCULOSIS Yes No HEARTBURN/REFLUX/ULCER Yes No EMPHYSEMA/COPD Yes No DIARRHEA/CONSTIPATION Yes No SINUS PROBLEMS Yes No LIVER DISEASE/HEPATITIS Yes No DIABETES Yes No ANEMIA Yes No THYROID DISEASE Yes No BLEEDING DISORDER Yes No STEROID USE Yes No SICKLE CELL DISEASE Yes No RHEUMATOID ARTHRITIS Yes No BLOOD CLOTS Yes No GOUT Yes No KIDNEY DISEASE Yes No OSTEOARTHRITIS Yes No BLADDER INFECTIONS Yes No SLEEP APNEA Yes No KIDNEY STONES Yes No MAJOR TRAUMA / FX Yes No INCONTINENCE Yes No CANCER Yes No SKIN PROBLEMS Yes No BLOOD TRANSFUSION Yes No VISUAL PROBLEMS Yes No NEUROLOGICAL DISORDER Yes No </p><p>If not listed above, please list any other MEDICAL CONDITIONS: ______Please list past SURGERIES: ______Please list all CURRENT MEDICATIONS/DOSES: Medications Dosage Times per day ______</p><p>Patient Signature: ______Date: ______</p>