"Orthopedic Surgery First-Time Office Visit Form - Montefiore"

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[web version]
Orthopedic Surgery First-Time Office Visit
YOUR BASIC INFORMATION:
Name:____________________________________________
Age: __________
Date of Birth: ____________
Primary care doctor: __________________________________________________
Today’s Date:____________
Did anyone refer you to us?
No
Yes, my primary care doctor
Height: ________________
Someone else [Please list: ________________]
Weight: ________________
REASON YOU ARE HERE TODAY:
What is the problem or injury?______________________________________________________________________
When did the problem start? _____________________ How severe is the pain? (1-10 scale) ____________________
Is this a work-related injury?
Yes
No
Is this injury from a motor vehicle accident?
Yes
No
ALLERGIES:
NONE
Latex
Penicillin
Aspirin
Iodine
Shellfish
Other:______________
MEDICATIONS YOU TAKE:
______________________________________________________________________
______________________________________________________________________________________________
OPERATIONS/SURGERY YOU HAVE HAD: __________________________________________________________
______________________________________________________________________________________________
MEDICAL HISTORY:
(Check any health problems that you have or have had, write any that are not listed)
Bleeding problems
Kidney disease
Arthritis
Asthma
Anemia
Liver disease
Gout
Diabetes
High blood pressure
Hepatitis [
A
B
C]
Parkinson’s
HIV or AIDS
Heart disease/heart attack
Colitis
Stroke/TIA
High Cholesterol
Atrial Fibrillation
Diverticulitis
Seizures
Other:
Pacemaker
Ulcers/GERD
Phlebitis/DVT (blood clot) __________________
Lung disease
Thyroid problems
Venereal disease
COPD/emphysema
Lupus
Cancer [Type: ____________________________]
HOW ARE YOU FEELING TODAY?:
(Check any symptoms that you have today, write any that are not listed)
Weight gain
Chest pain
Joint pain
Urinary infections
Weight loss
Shortness of breath
Weakness
Rashes
Headaches
Palpitations
Paralysis
Lumps
/C
S
/C
D
/T
REDENTIALS
IGNATURE
REDENTIALS
ATE
IME
Blackouts
Cough
Low back pain
Dizziness
Abdominal pain
Painful urination
Other:
_
Double vision
Bloody stool
Bloody urine
______________
MEDICAL PROBLEMS THAT RUN IN YOUR FAMILY:
Diabetes
Heart disease
High blood pressure
Arthritis
Other: ______________
PERSONAL HISTORY:
What kind of work do you do? ________________________________
Retired
Disability
Unemployed
Marital status:
Single
Married
Divorced
Widowed
Living situation:
Alone
w/Spouse
w/Family
w/Significant other
Other
Smoking:
Most/every day
Some days
Former smoker
Never smoked
QOD
U
IU
MS
MS0
.Xmg
If yes, how much?___________________
For how many years? __________________
4
W
Every other day Unit
International Unit Morphine Sulfate Magnesium Sulfate
Xmg
0.Xmg
Do you drink any alcohol?
Never
Occasional
Frequent
Do you use any other drugs?
None
____________________
R
P
P
N
S
/C
D
/T
EVIEWING
HYSICIAN
RINT
AME
IGNATURE
REDENTIALS
ATE
IME
MMC4315 (3/13)
[web version]
Orthopedic Surgery First-Time Office Visit
YOUR BASIC INFORMATION:
Name:____________________________________________
Age: __________
Date of Birth: ____________
Primary care doctor: __________________________________________________
Today’s Date:____________
Did anyone refer you to us?
No
Yes, my primary care doctor
Height: ________________
Someone else [Please list: ________________]
Weight: ________________
REASON YOU ARE HERE TODAY:
What is the problem or injury?______________________________________________________________________
When did the problem start? _____________________ How severe is the pain? (1-10 scale) ____________________
Is this a work-related injury?
Yes
No
Is this injury from a motor vehicle accident?
Yes
No
ALLERGIES:
NONE
Latex
Penicillin
Aspirin
Iodine
Shellfish
Other:______________
MEDICATIONS YOU TAKE:
______________________________________________________________________
______________________________________________________________________________________________
OPERATIONS/SURGERY YOU HAVE HAD: __________________________________________________________
______________________________________________________________________________________________
MEDICAL HISTORY:
(Check any health problems that you have or have had, write any that are not listed)
Bleeding problems
Kidney disease
Arthritis
Asthma
Anemia
Liver disease
Gout
Diabetes
High blood pressure
Hepatitis [
A
B
C]
Parkinson’s
HIV or AIDS
Heart disease/heart attack
Colitis
Stroke/TIA
High Cholesterol
Atrial Fibrillation
Diverticulitis
Seizures
Other:
Pacemaker
Ulcers/GERD
Phlebitis/DVT (blood clot) __________________
Lung disease
Thyroid problems
Venereal disease
COPD/emphysema
Lupus
Cancer [Type: ____________________________]
HOW ARE YOU FEELING TODAY?:
(Check any symptoms that you have today, write any that are not listed)
Weight gain
Chest pain
Joint pain
Urinary infections
Weight loss
Shortness of breath
Weakness
Rashes
Headaches
Palpitations
Paralysis
Lumps
/C
S
/C
D
/T
REDENTIALS
IGNATURE
REDENTIALS
ATE
IME
Blackouts
Cough
Low back pain
Dizziness
Abdominal pain
Painful urination
Other:
_
Double vision
Bloody stool
Bloody urine
______________
MEDICAL PROBLEMS THAT RUN IN YOUR FAMILY:
Diabetes
Heart disease
High blood pressure
Arthritis
Other: ______________
PERSONAL HISTORY:
What kind of work do you do? ________________________________
Retired
Disability
Unemployed
Marital status:
Single
Married
Divorced
Widowed
Living situation:
Alone
w/Spouse
w/Family
w/Significant other
Other
Smoking:
Most/every day
Some days
Former smoker
Never smoked
QOD
U
IU
MS
MS0
.Xmg
If yes, how much?___________________
For how many years? __________________
4
W
Every other day Unit
International Unit Morphine Sulfate Magnesium Sulfate
Xmg
0.Xmg
Do you drink any alcohol?
Never
Occasional
Frequent
Do you use any other drugs?
None
____________________
R
P
P
N
S
/C
D
/T
EVIEWING
HYSICIAN
RINT
AME
IGNATURE
REDENTIALS
ATE
IME
MMC4315 (3/13)