"New Patient Form - Vanderbilt Orthopaedic Institute, the Vanderbilt Hand Center, Hand and Upper Extremity"

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VANDERBILT ORTHOPAEDIC INSTITUTE
PATIENT NAME: ____________________
THE VANDERBILT HAND CENTER
DATE OF BIRTH: ____________________
HAND AND UPPER EXTREMITY
MEDICAL RECORD: _________________
DATE OF SERVICE: _________________
New Patient Form
PHYSICIAN: ________________________
PLEASE PRINT
PHONE NO.: _______________________________
ADDRESS: __________________________________ CITY: _______________________ STATE: ________ ZIP: ______________
REFERRING PHYSICIAN: ____________________________________________________________________________________
ADDRESS: ____________________________ CITY: _______________ STATE: ________ZIP: ________ PHONE: ____________
FAMILY PHYSICIAN (NAME): ______________________________________ PHONE NO.: ______________________________
CHIEF COMPLAINT: _______________________________________________________ PAIN SCALE: 1 2 3 4 5 6 7 8 9 10
DATE OF INJURY: __________________ DOMINANT HAND:
RIGHT
LEFT
INJURED HAND:
RIGHT LEFT
Place of Employment: _________________________________
How Long: ____________
Type of Work:
Sedentary
Heavy Labor
Occupation: ___________________________________
Present Work Status:______________________________________________________________________________________
Previous Work Comp Injuries: ______________________________________________________________________________
OTHER ILLNESSES YOU NOW HAVE (IF ANY):
PLEASE LIST ALL MEDICINES YOU ARE NOW TAKING:
__________________________________________
___________________________________________________
__________________________________________
___________________________________________________
__________________________________________
___________________________________________________
PRESENT WEIGHT: ________ HEIGHT: _______
___________________________________________________
PAST HISTORY- REVIEW OF SYMPTOMS (Circle Yes or No) If yes is NOT circled, response will be considered negative.
HAVE YOU EVER HAD or CURRENTLY EXPERIENCING:
Free Bleeding
Yes
No
Fainting Spells
Yes
No
Stomach Ulcers
Yes
No
Heart Trouble
Yes
No
Anemia (low Blood)
Yes
No
Kidney Trouble
Yes
No
Chest Pain
Yes
No
Numbness in Extremities Yes
No
Varicose Veins
Yes
No
Irregular Heart Beat
Yes
No
Asthma
Yes
No
Leg Swelling
Yes
No
High Blood Pressure
Yes
No
Emphysema
Yes
No
Poor Circulation
Yes
No
Stroke
Yes
No
Anesthesia Problems
Yes
No
Diabetes
Yes
No
Paralysis
Yes
No
Spitting up Blood
Yes
No
Steroid Medication
Yes
No
Fever with Surgery
Yes
No
Thyroid Trouble
Yes
No
Blood Thinner Pills
Yes
No
Seizures
Yes
No
Back Ache (Severe)
Yes
No
Blood Clot in Legs
Yes
No
Ringing in Ears
Yes
No
Addiction Problems
Yes
No
Blood Clot in Lungs
Yes
No
Dizziness
Yes
No
Hepatitis
Yes
No
Blood Transfusion
Yes
No
Visual Changes
Yes
No
Jaundice
Yes
No
Cancer
Yes
No
Hypertension
Yes
No
Fever/Chills
Yes
No
Other: _________________________
ARE YOU ALLERGIC TO:
Penicillin
Yes
No
Sulfa
Yes
No
“Mycin”
Yes
No
Aspirin
Yes
No
Codeine
Yes
No
Tetanus
Yes
No
Demerol
Yes
No
Other Medicine: Please List: ________________________________________________
FAMILY MEDICAL HISTORY
If yes is NOT circled, response will be considered negative.
HAS ANY BLOOD RELATIVE EVER HAD:
WHO
Bone Disease
Yes
No
__________________
Mental Illness
Yes
No
______________
Osteoporosis
Yes
No
__________________
Arthritis
Yes
No
______________
Tuberculosis
Yes
No
__________________
Congenital Deformities
Yes
No
______________
Diabetes
Yes
No
__________________
Kidney Trouble
Yes
No
______________
Heart Trouble
Yes
No
__________________
Anesthesia Problems
Yes
No
______________
High Blood Pressure
Yes
No
__________________
Cancer
Yes
No
______________
Stroke
Yes
No
__________________
Fever with Surgery
Yes
No
______________
Joint Contractures
Yes
No
__________________
Bleeding Disorders
Yes
No
______________
VANDERBILT ORTHOPAEDIC INSTITUTE
PATIENT NAME: ____________________
THE VANDERBILT HAND CENTER
DATE OF BIRTH: ____________________
HAND AND UPPER EXTREMITY
MEDICAL RECORD: _________________
DATE OF SERVICE: _________________
New Patient Form
PHYSICIAN: ________________________
PLEASE PRINT
PHONE NO.: _______________________________
ADDRESS: __________________________________ CITY: _______________________ STATE: ________ ZIP: ______________
REFERRING PHYSICIAN: ____________________________________________________________________________________
ADDRESS: ____________________________ CITY: _______________ STATE: ________ZIP: ________ PHONE: ____________
FAMILY PHYSICIAN (NAME): ______________________________________ PHONE NO.: ______________________________
CHIEF COMPLAINT: _______________________________________________________ PAIN SCALE: 1 2 3 4 5 6 7 8 9 10
DATE OF INJURY: __________________ DOMINANT HAND:
RIGHT
LEFT
INJURED HAND:
RIGHT LEFT
Place of Employment: _________________________________
How Long: ____________
Type of Work:
Sedentary
Heavy Labor
Occupation: ___________________________________
Present Work Status:______________________________________________________________________________________
Previous Work Comp Injuries: ______________________________________________________________________________
OTHER ILLNESSES YOU NOW HAVE (IF ANY):
PLEASE LIST ALL MEDICINES YOU ARE NOW TAKING:
__________________________________________
___________________________________________________
__________________________________________
___________________________________________________
__________________________________________
___________________________________________________
PRESENT WEIGHT: ________ HEIGHT: _______
___________________________________________________
PAST HISTORY- REVIEW OF SYMPTOMS (Circle Yes or No) If yes is NOT circled, response will be considered negative.
HAVE YOU EVER HAD or CURRENTLY EXPERIENCING:
Free Bleeding
Yes
No
Fainting Spells
Yes
No
Stomach Ulcers
Yes
No
Heart Trouble
Yes
No
Anemia (low Blood)
Yes
No
Kidney Trouble
Yes
No
Chest Pain
Yes
No
Numbness in Extremities Yes
No
Varicose Veins
Yes
No
Irregular Heart Beat
Yes
No
Asthma
Yes
No
Leg Swelling
Yes
No
High Blood Pressure
Yes
No
Emphysema
Yes
No
Poor Circulation
Yes
No
Stroke
Yes
No
Anesthesia Problems
Yes
No
Diabetes
Yes
No
Paralysis
Yes
No
Spitting up Blood
Yes
No
Steroid Medication
Yes
No
Fever with Surgery
Yes
No
Thyroid Trouble
Yes
No
Blood Thinner Pills
Yes
No
Seizures
Yes
No
Back Ache (Severe)
Yes
No
Blood Clot in Legs
Yes
No
Ringing in Ears
Yes
No
Addiction Problems
Yes
No
Blood Clot in Lungs
Yes
No
Dizziness
Yes
No
Hepatitis
Yes
No
Blood Transfusion
Yes
No
Visual Changes
Yes
No
Jaundice
Yes
No
Cancer
Yes
No
Hypertension
Yes
No
Fever/Chills
Yes
No
Other: _________________________
ARE YOU ALLERGIC TO:
Penicillin
Yes
No
Sulfa
Yes
No
“Mycin”
Yes
No
Aspirin
Yes
No
Codeine
Yes
No
Tetanus
Yes
No
Demerol
Yes
No
Other Medicine: Please List: ________________________________________________
FAMILY MEDICAL HISTORY
If yes is NOT circled, response will be considered negative.
HAS ANY BLOOD RELATIVE EVER HAD:
WHO
Bone Disease
Yes
No
__________________
Mental Illness
Yes
No
______________
Osteoporosis
Yes
No
__________________
Arthritis
Yes
No
______________
Tuberculosis
Yes
No
__________________
Congenital Deformities
Yes
No
______________
Diabetes
Yes
No
__________________
Kidney Trouble
Yes
No
______________
Heart Trouble
Yes
No
__________________
Anesthesia Problems
Yes
No
______________
High Blood Pressure
Yes
No
__________________
Cancer
Yes
No
______________
Stroke
Yes
No
__________________
Fever with Surgery
Yes
No
______________
Joint Contractures
Yes
No
__________________
Bleeding Disorders
Yes
No
______________
SOCIAL HISTORY (Circle Yes or No)
If yes is NOT checked, response will be considered negative.
DO YOU
Smoke or use other tobacco products
Yes
No
If yes, how many packs per day __________________
Drink alcoholic beverages
Yes
No
If yes, average drinks per day ____________________
Please advise your physician of any cultural or spiritual issues that may affect you care:
Marital Status:
Single
Married
Widowed
Divorced
Number of Children (if any):_______________
LIST ANY OPERATIONS HAD:
OPERATION
DATE
SURGEON
HOSPITAL
_____________________________
_______________
___________________
_________________________
_____________________________
_______________
___________________
__________________________
_____________________________
_______________
___________________
__________________________
_____________________________
_______________
___________________
__________________________
_____________________________
_______________
___________________
__________________________
LIST ANY TESTING OR IMAGING THAT HAS BEEN DONE AND WHERE (EXAMPLE: EMG, NCV, MRI, X-RAYS)
__________________________________________
__________________________________________________
__________________________________________
__________________________________________________
__________________________________________
__________________________________________________
ADDITIONAL NOTES & COMMENTS:
PATIENT SIGNATURE: _______________________________________________________ DATE: ________________________
I HAVE REVIEWED THE INFORMATION PROVIDED ABOVE.
PHYSICIAN SIGNATURE: ____________________________________________________ DATE: _________________________
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