Name (first, middle, last): Date:

Date of Birth: Age: Height: Weight:

Marital Status: Single Married Separated Divorced Widowed N/A

Occupation: Homemaker Student Unemployed

Primary Care Dr: Referring Dr:

CHIEF COMPLAINT

Reason for visit (Body Part)? Date of Injury/Onset of Problem:

How did your injury occur?

Did your injury occur at? Home School Work Sports/recreational other: ________________

Is the injury related to a motor vehicle accident? YES NO If YES, were you: Driver Passenger Pedestrian Cyclist

Other:

Were you seen in the Emergency Room, Urgent Care, or by any physician? Yes No If YES, where and when?

Are you right- or left-hand dominant? Right Left PAIN SCALE please rate the intensity of your pain on a scale of 1 to 10, 0 = no pain, ten = extreme pain.

What makes the pain worse? What decreases the pain?

REVIEW OF SYSTEMS Please circle any symptoms you are currently experiencing or being treated for. Const. (Health in General) No Problems Lack of energy, unexplained weight gain or weight loss, loss of appetite, fever, night sweats, prior diagnosis of cancer. Ears, Nose, Mouth & Throat No Problems Difficulty with hearing, sinus problems, ringing in ears, mouth sores, loose teeth, ear pain, nosebleeds. C-V (Heart & Blood Vessels) No Problems Irregular heartbeat, A- Fib, racing heart, chest pains, swelling of feet or legs, pain in legs with walking. Resp. (Lungs & Breathing) No Problems Shortness of breath, prolonged cough, wheezing, prior tuberculosis, pleurisy, coughing up blood, abnormal chest x-ray. GI & GU (Stomach, Intestines, Kidney & Bladder) No Problems Heartburn, constipation, intolerance to certain foods, diarrhea, abdominal pain, difficulty swallowing, nausea, vomiting, blood in stools, unexplained change in bowel habits, incontinence, prostate problems, bladder problems, impotence. MS (Muscles, Bones, Joints) No Problems Joint pain, aching muscles, shoulder pain, swelling of joints, joint deformities, back pain. Integ. (Skin, Hair & Breast) No Problems Rash, itching, skin lesion(s), hair loss or increase, breast changes. Neurologic (Brain & Nerves) No Problems Frequent headaches, weakness, change in sensation, problems with walking or balance, dizziness, tremor, loss of consciousness, uncontrolled motions, seizures. Psychiatric (Mood & Thinking) No Problems Insomnia, irritability, depression, anxiety, recurrent bad thoughts, mood swings, hallucinations, compulsions. Endocrine (Glands) No Problems Intolerance to heat or cold, menstrual irregularities, frequent hunger/urination/thirst, changes in sex drive. Hematologic (Blood/Lymph) No Problems Easy bleeding, easy bruising, anemia, abnormal blood tests, leukemia, unexplained swollen areas. Allergic/Immunologic No Problems Seasonal allergies, hay fever symptoms, itching, frequent infections, exposure to HIV. OTHER SYMPTOMS NOT DESCRIBED ABOVE: _________________________________________________________________

Please turn over and complete the next page

PATIENT MEDICAL HISTORY

MEDICATIONS Please list all medication you take with or without a prescription (use extra paper if necessary)

Medication Name Dosage/Number Per Day Reason for Taking

ALLERGIES Please describe any current or past allergic reactions ! I DO NOT have any drug allergiesAllergy To (drug name) Reaction (itching, cough, hives, etc)

SURGERIES AND HOSPITALIZATION Please list any surgeries or major hospitalizations you have had and the corresponding year. ! I HAVE NOT HAD any surgeries or hospitalizations ______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

MEDICAL HISTORY Have you been diagnosed or do you have a history of any of the following conditions or diseases?

Yes No Yes No Yes No Yes No ! ! Anemia ! ! Gallbladder Removal ! ! Liver Disease ! ! Rheumatic Fever! ! Arthritis (Rheumatoid) ! ! Gout ! ! Lung Disease ! ! Sexually Transmitted! ! Asthma ! ! Heart Disease ! ! Phlebitis Disease (STD)! ! Birth Defects ! ! Hepatitis Type________ ! ! MRSA/Staph Infection ! ! Stroke/TIA! ! Bladder Disease ! ! HIV/AIDS ! ! Osteoporosis ! ! Tuberculosis! ! Bleeding or Bruising ! ! High Blood Pressure ! ! Peripheral Vascular ! ! Thyroid (Hyper/Hypo)! ! Cancer Type__________ ! ! High Cholesterol Disease ! ! Ulcer Type________! ! Diabetes Type ________ ! ! Intestinal/Bowel ! ! Polio! ! DVT/Blood Clots Disease ! ! Psychological Problems! ! Epilepsy ! ! Kidney Disease/Failure ! ! Pulmonary Embolism

No

Are there any other medical problems we should know about? Are you or could you be pregnant? !Yes !No Have you had a bone scan (DEXA)? Yes when? Have you been diagnosed with osteopenia or osteoporosis? Yes NoFAMILY HISTORY Have your mother, father, grandparents, brothers or sisters been treated in the past or are they currently receiving treatment for any of the following conditions?

Yes No Yes No Yes No Other ! ! Alzheimers ! ! Diabetes Type ________ ! ! Osteoporosis _____________________________ ! ! Arthritis ! ! Gout ! ! Stroke _____________________________ ! ! Cancer Type__________ ! ! Heart Disease ! ! Sudden Death _____________________________

SOCIAL HISTORY

Amount and frequency: ___________________________________ Type and frequency: _____________________________________ Frequency: _____________________________________________

packs per day for years

Patient/Guardian Signature: Date:

! ! ! !

! Yes! Yes! Yes! Yes

Do you smoke or chew tobacco? Do you drink alcoholic beverages?Do you use recreational drugs?Do you exercise or participate in sports regularly?

Do you have an advanced directive, plan of care, surrogate decision maker or health care proxy? ! Yes ! No Do you wish to participate in Countryside Orthopaedics portal? No Yes

Number! No! No! No! No