<p> Felasfa M. Wodajo, MD Musculoskeletal Tumor Surgery</p><p>New Patient Questionnaire</p><p>Thank you for filling out this information that will help us take better care of you.</p><p>Today’s date: </p><p>Name: </p><p>Date of birth: </p><p>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). </p><p>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:</p><p>List any medicines, vitamins, or herbal supplements that you take now.</p><p>Allergies? Do you have a latex allergy? </p><p>Do you smoke cigarettes now or ever smoked? If yes, how many per day? and for how many years?</p><p>Do you drink alcohol? If yes, how many drinks in one week?</p><p>1 Your occupation:</p><p>Has anyone in your family had a cancer diagnosis? If yes, list the family member and what type of cancer.</p><p>List any previous surgeries and dates:</p><p>Write yes beside any medical conditions you have had: </p><p>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</p><p>Your height: Your weight: </p><p>2 Write yes beside any problem you have had in the last six months:</p><p>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</p><p>Thank you! </p><p>Please sign this form: </p><p>3</p>