History new general patient (42

2003. Sparrow Systems, Inc. Patent Pending.
General Patient History
Location of Worst Problem (if you are seeing us for more than 1 problem) Please describe your current problem? (If you are seeing the doctor for multiple problems, answer for the most severe) New Injury or problem (less than 3 months duration)Subacute problem (began slowly with no identifiable cause and progressively worsened)Chronic problem (problem has been present over time period of more than 3 months and never been restored to normal)Re-injury (you injured this same area before, received treatment, had no problems until this new injury occurred) Date problem began (approximate if unsure) ANSWER THE QUESTIONS IN THIS BOX ONLY IF YOUR PROBLEM IS THE RESULT OF AN INJURY
If your problem is the result of an injury, where did it occur? (check one answer only) Check any of the following that happened at the time of your injury Have you talked to a lawyer concerning your injury? Are you receiving or have you applied for workers compensation concerning your injury? Have you received previous treatment for your current problem? If yes, please specify treatment type (check all that apply) and provide the # of the procedures or
weeks of physical therapy you have had for the specific problem you are seeing the doctor for today
Please tell us your height and weight
Physician You are Seeing Today (write only first and last name, do not write "Dr.") Referring Physician (write only first and last name, do not write "Dr.") Review of Systems
Please check all problems you currently experience - You may check more than one answer for each category.
If a problem does not apply to you DO NOT put any marks in the box.
Check this box if none of the following symptoms apply to you TODAY
Kidney, Bladder, Reproductive (Genitourinary)
Overall General Health
difficulty starting urinewetting pants or bed Heart & Blood Vessels (Cardiovascular)
Endocrine & Metabolic
Blood (Hematopoietic / Lymphatic)
Abdomen (Gastrointestinal)
Psychiatric
Lungs (Respiratory)
Brain, Nerves, Spinal Cord (Neurologic)
Bone & Joint (Musculoskeletal)
IN ORDER TO INSURE PROPER AND COMREHENSIVE CARE, YOU MUST FOLLOW-UP WITH YOUR
PRIMARY CARE PHYSICIAN FOR ANY AND ALL MEDICAL PROBLEMS AND CONCERNS CHECKED HERE.
·Please check any of the following conditions you have or have had in the past.
·If you are unsure, please ask a staff member to assist you in filling out this form.
You may check more than one condition.
Medical Condition History
Check this box if you have no medical problems
Arthritis - rheumatoid (verified with blood test) Hypercholesterolemia (Elevated Cholesterol) COPD (Chronic Obstructive Pulmonary Disease) Surgery/ Procedures These are non-orthopaedic procedures. Please check any procedures you have had and give the year.
Have you ever had surgery?
Ear, Nose, Throat Surgeries
General Surgeries
Heart (Cardiac) Surgeries
Gastrointestinal Surgeries
Vascular Surgeries
Thoracic Surgeries
Gynecologic Surgeries
Neurosurgeries
Urologic Surgeries
Prostatectomy (Prostate Removed)Vasectomy Orthopaedic Surgery/ Procedures Please check any procedures you have had and give the year.
(if same surgery performed more than once) Broken Bones/Fracture Repair Surgeries
Ankle/Foot Surgeries
Elbow, Wrist, Hand Surgeries
Knee Surgeries
Hip Surgeries
Shoulder Surgeries
Spine Surgeries
Other (List all other surgeries) _______________________________________________________________________________________ __________________________________________________________________________________________________________________ Drug Allergy and Medication Information
Have you ever had problems with anesthesia? If yes, describe________________________________ No If yes, please write the name of the drug in the boxes below and check the reaction you experienced. Please write only one drug in each space provided. If you have more than 3 drug allergies list the others in the space provided. Please list additional drug allergies here: ____________________________________________________________________________________________________________________________________________________________________ Please check any anti-inflammatory medication listed below which you have taken in the past. Please include all prescription, non-prescription and samples Please check any of the following side effects you experienced while taking any of the above anti-inflammatory medications.
Please check any of the following medications you take on a regular basis.
Please list the medications you are currently taking - Please include prescription and non-prescription medication _______________________________ __________________________________ _________________________ _______________________________ __________________________________ _________________________ _______________________________ __________________________________ _________________________ _______________________________ __________________________________ _________________________ Family Medical History
Please check all diseases for which you have a family history: If you know your parents' health history please provide the information below. Otherwise, please leave blank.
deceased Age (current age or age deceased) Current Employment (Check only ONE answer) Level of Education (Check only ONE answer) Social History
rarely (less than 1 drink a month)occasionally (1-4 drinks per month) I do not drink alcohol, but I used to drink alcohol frequently (3-5 drinks per week)daily (at least one drink a day) If you use or used to use tobacco, cigarette packs per day I do not use tobacco, but I used to use tobacco Symptoms and Pain Survey
Compared to 3 months ago, how would you rate your symtoms now? Compared to 3 months ago, how worried are you about your condition now? On a scale of 0-10 (with 10 being the worst pain imaginable), how would you score your pain today? Check the words that best describe the character of the pain you are having today.
What time of day is your pain worst (CHECK ONLY ONE)? If you had to spend the rest of your life with your condition the way it is now, how would you feel about it?
SF-12 - Check ONLY ONE answer for each question
Hand Dominance:
Use both equally
Instructions: This survey asks for your views about your health. This information will help keep trackof how you feel and how well you are able to do your usual activities. Please answer every questionby marking one box. If you are unsure about how to answer, please give the best answer you can.
1. In general, would you say your health is: (#2 and #3) The following items are about activities you might do during a typical day.
Does your health now limit you in these activities? If so, how much?
2. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf (#4 and #5) During the past 4 weeks, have you had any of the following problems with your work or other regular
daily activities as a result of your physical health?
5. Were limited in the kind of work or other activities (#6 and #7) During the past 4 weeks, have you had any of the following problems with your work or other regular daily
activities as a result of any emotional problems (such as feeling depressed or anxious)?
7. Didn't do work or perform other activities as carefully as usual 8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? (#9, #10 and #11) These questions are about how you feel and how things have been with you during the past 4 weeks.
For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks
12. During the past 4 weeks, how much of the time has your physical or emotional problems interfered with yoursocial activities (like visiting with friends, relatives, etc)? PLEASE RETURN THIS COMPLETED PACKET TO THE FRONT DESK NOW

Source: http://atlantasportsmedicine.com/orthopedic-surgeon/wp-content/uploads/2014/01/HistoryGeneral.pdf