Date : MRN :

Primary Care Physician :

Are you a Student Attending What School?

UF Orthopaedics & Sports Medicine Institute

General : Age : Date of Birth :

Race :

Medical History Yes No Yes No Yes NoAllergies------------------------------------ Lung Disease---------------- Meningitis--------------------------------Anemia-------------------------------------- Nerve / muscle disease--------------Anxiety-------------------------------------- Osteoporosis----------------------------Arthritis-------------------------------------- Acid Reflux-------------------- Seizures----------------------------------Asthma-------------------------------------- Glaucoma---------------------- Sickle Cell--------------------------------Blood Transfusion------------------------ Gout----------------------------- Stroke-------------------------------------Cancer-------------------------------------- Substance Abuse----------------------Cataracts----------------------------------- Thyroid Disease------------------------Congestive Heart Failure--------------- Tuberculosis-----------------------------Clotting disorder (i.e., blood clot)----- High Cholesterol------------ Ulcers-------------------------------------High Blood Pressure------------------- Anesthetic Complications------------

AdultsIrregular periodsFrequent spottingAre you pregnant?

Surgical History Yes No Yes No Yes No

Are you nursing?

Appendix---------------------------------- Cosmetic surgery------------- Joint replacement-----------------------Brain surgery----------------------------- Small intestine surgery----------------Breast surgery---------------------------- Spine surgery----------------------------Open Heart or Bypass----------------- Fracture surgery -------------- Tubes Tied-------------------------------Gall Bladder------------------------------- Valve replacement---------------------Colon Surgery-----------------------------

Patient Name :

Referring Physician :

Date of Injury :

Depression---------------------

Hernia repair-------------------Hysterectomy-------------------

C-Section------------------------Eye surgery---------------------

Kidney Disease---------------HIV/AIDS-----------------------Heart Attack-------------------

1

Caucasian African-American OtherAsianHispanic

Yes No

Male Female

Diabetes Mellitus-------------

Occupation

Occupation

If yes, When?Are you Retired Yes No

Any Other Medical History:

Any Other Surgical History:

Pharmacy :

Pediatric Patients Only

Female Patients Only

Labor and DeliveryDuration of Preganancy:(Not length of labor)

Vaginal C- SectionDelivery:Birth weight:

Development

Age at sitting:

Age at walking: NoYesImmunizations up-to-date?

Female Menstrual History (Females over age 10)Have you started your periods? NoYes

NoYesNoYesNoYesNoYes

If yes, at what age?

When was your last period?

Pharmacy Address :

Patient lives with: Is the patient adopted?

Brothers: Sisters: Grade in school:

2

NoYes

Social History

Tobacco UseFormer Use-------------- Packs/day Quit Date # of Years

Smokeless tobacco--- Quit Date

Alcohol Use------------- Glasses of Wine

Comments

Drinks/Week

Cans of BeerShots of liquorDrinks containing 0.5 oz of alcohol

Drug Use-----------------Per Week

NoYes

NoYes

NoYes

NoYesMethamphetaminesMarijuana

Cocaine IV

Types

Comments

RelationshipMother----------Father----------Sister-----------Brother---------Maternal AuntMaternal UnclePaternal AuntPaternal UncleMaternal GMMaternal GFPaternal GMPaternal GF

Other

Arth

ritis

Asth

mas

Birt

h D

efec

ts

Canc

er

Dep

ress

ion

Dia

bete

s

Early

Dea

th

Hea

rt D

iseas

e

Hig

h Bo

old

Pres

sure

Hig

h Ch

oles

tero

l

Kidn

ey D

iseas

e

Lear

ning

disa

bilit

y

Men

tal I

llnes

s

Oth

er

Subs

tanc

e Ab

use

Visio

n Lo

ss

Family Medical History Instructions: Please check the box of positive family medical history. Paternal = Fathers Side. Maternal = Mothers SideKey:

Stro

ke

Reason for Today’s Visit:

Is visit due to Injury or Accident?

How did it happen?

What treatment or tests have you had for this current problem?

What activities make your pain worse? What activities make your pain better?

How far can you walk? What stops you? When are your problems most severe?What is your normal sleeping position? Have you had this problem before: Previous treatment?

Exercise prior to this problem: Regularly?Are your complaints affecting your ability to exercise or generally be active? Additional questions:

If Yes, Then when:

Do you frequently feel pain in your chest or heart ?Do you know of any other reason why you should not do physical activity ?

Pain Rating: On a scale of zero to ten 0 (zero) being no pain ------ 10 (ten) being the worst pain imaginable

How would you rate the intensity of your pain?

How stressful is the pain you are feeling?

Since this problem began is the problem :

Your goals for treatment are:

Now Worst Day Best Day

Current Problem

3

NoYes Surgery Date:Injury Date:

Surgery CT ScanSplint/Brace Xrays

Physical Therapy Massage Therapy :

Injection EMGChiropractic Treatment :Occupational TherapyOther Diagnostic Tests : MRI

# of visits:# of visits:

Types:

Morning Consistent all dayEveningAfternoon

Stomach Side lying Back

NoYes

If Yes, Then what: NoYes

Your current pain: Indicate on the diagram below the location of your current pain. Do not indicate areas of pain which are not related to your present problem:

Pain location: (indicate on diagram)

NoYes

NoYes

NoYes

What/How Often? NoYes

Increasing Decreasing Unchanged

5 8 96 7 103 41 20

5 8 96 7 103 41 20

5 8 96 7 103 41 20

Now Worst Day Best Day

5 8 96 7 103 41 20

5 8 96 7 103 41 20

5 8 96 7 103 41 20

x Dull/aching pain ^ Sharp pain+ Pins and Needles = Numbness

^x

=+

^x

=+

^x

=+

^x

=+

^x

=+

^x

=+

^x

=+

^x

=+

^x

=+

^x

=+

^x

=+

^x

=+

^x

^x

=+

^x

=+

Upper Upper

Lower Lower

=+

CURRENT MEDICATIONS: PRESCRIPTION/NON-PRESCRIPTION ALLERGIES (MEDICATIONS, FOOD, SEASONAL, ETC)

DESCRIBE ADVERSE REACTIONNAME OF MEDICATIONSTRENGTH/DOSENAME OF MEDICATION HOW DO YOU TAKE IT?

4

Patient Signature: Date:

Constitutional Yes No Yes No Yes NoFever------------------------------------ Blurred Vision----------------------- Heartburn---------------------------Chills-------------------------------------- Nausea-------------------------------

Vomiting----------------------------Weight Loss-----------------------------

Eye Discharge----------------------Stomach Pain----------------------Fatigue-----------------------------------

Eye Redness-----------------------Diarrhea------------------------------Profuse Sweating----------------------Constipation--------------------------Weakness--------------------------------Blood in Stool-----------------------Dark Tarry Stools---------------------

Double Vision-----------------------

Eye Pain----------------------------Sensitive to Light-------------------

Yes NoEasy Bruise/bleed--------------------Environmental Allergies------------Polydipsia (Excessive thirst)--------

Skin Yes No Yes No Yes NoRash------------------------------------ Chest pain------------------------- Painful Urination---------------------Itching-------------------------------------- Urgency------------------------------

Frequency---------------------------Blood in Urine------------------------Side Pain-----------------------------Leg Swelling----------------------

Pounding Heart-------------------

Shortness of breath during Sleep / Rest---------------------------

Shortness of breath relieved by sitting up------------------------------

Yes NoDizziness----------------------------Tingling-------------------------------Tremors--------------------------------Change in Sense of Touch--------Speech Change----------------------Hand, Arm, or Leg WeaknessSeizures------------------------------Loss of Consciousness----------

Head,Ears,Nose, & Throat Yes No

Yes No

Headaches------------------------------------

Muscle Pain-------------------------

Hearing Loss----------------------------

Neck Pain---------------------------

Ring in ears-------------------------------

Back Pain----------------------------

Ear Pain------------------------------------

Joint Pain----------------------------

Ear Discharge----------------------------

Falls------------------------------------

Nose Bleeds-------------------------------Congestion--------------------------------Wheezing---------------------------------Sore Throat-------------------------------

Yes NoDepression--------------------------Suicidal Ideas-----------------------Substance Abuse---------------------Hallucinations-------------------------Nervous/Anxious---------------------Sleeping Disorder-------------------Memory Loss--------------------------

Eyes Gastrointestinal Endo/Heme/Allergies

Neurological

GenitourinaryCardiovascular

Musculoskeletal

Psychiatric

Yes NoCough--------------------------------Coughing up Blood------------------Phlegm Production------------------Shortness of Breath------------------Wheezing--------------------------

Respiratory

Please indicate if you are currently experiencing any of the following conditions:

5

Any Other Symptoms:

Review of Systems

Have you had any changes to your health?

Have you been diagnosed with any conditions or diseases?

Have you had any surgical or invasive procedures?

If Yes, Please Explain :NoYes

NoYes

NoYes

SINCE YOUR LAST VISIT:

If Yes, Please Explain :

If Yes, Please Explain :