FELLOWSHIP TRAINED SURGICAL SUBSPECIALISTS

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Patient Name: ---------- DOB:------

DATE: _ MR#: -----

ANTHONY INFANTE DO - PATIENT HISTORY PATIENT INFORMATION

Primary Physician Information Who referred you? Family/Primary Patient:Physician:Family/Primary Doctor:Physician address Friend:and phone#:

Advertising:Other:

Marital Status: Handed: Height/Wei~ ht Occupation: D single, D right HeightD married D leftD divorced D both WeightD widowed

Sex: □Male □Female

Current Work Status: D employed D not working0 retired D light duty

Have you seen a doctor in the past for this problem or injury? If yes, who, when and where?

In your own words, please describe how your injury occured?

8/6/2013 1

Patient Name: _DOB:------

DATE: _ MR#: ·-----

MEDICAL CONDITION HISTORY

Medical Condition History: D NO MEDICAL PROBLEMS 0 DepressionD Alcoholism 0 GoutD Anemia □ HIVD Anxiety □ Hypertension (High Blood Pressure)D Asthma □ Hypercholesterolemia (Elevated

Cholesterol)D Arthritis -inflammatory □ Hypothyroidism

(rheumatoid)D Arthritis - osteo, 0 Kidney Disease

deaenerativeD Bowel disease □ Liver Disorder (Cirrhosis, Hepatitis)D Cancer 0 Lung Disease (COPD, emphysema)D Cardiac Arrhythmia □ Osteomyelitis

(Abnormal heart rate)D Congestive Heart Failure 0 Parkinson'sD Coronary Artery Disease □ Ulcer Disease

(Anainal□ Cerebrovascular Disease □ Other

(Stroke)□ Diabetes

Other Medical Condition: Have you ever had a blood clot? □ I Yes I □ !No

Have you every had a blood transfusion? □ I Yes I □ !No

8/6/2013 2

Patient Name: ---------- DOB: ------

DATE: _ MR#: ------

SURGERY /PROCEDURES

Arthroscopy Fracture Repair D right shoulder D left shoulder D right shoulder D left shoulder

D right elbow D left elbow D right arm D left arm

D right wrist/hand D left wrist/hand D right elbow D left elbow

D right hip D left hip D right forearm D left forearm

D right knee D left knee D right D leftwrist/hand wrist/hand

D right foot/ankle D left foot/ankle D right pelvis D left pelvis

D right hip D left hip

Joint Replacement Surgery D right femur D left femur(thlohl (thigh)

D right shoulder D left shoulder D right knee D left knee

D right elbow D left elbow D right D lefttibia/fibula tibia/fibula

D right wrist/hand D left wrist/hand D right D leftfoot/ankle foot/ankle

D right hip D left hip

D right knee D left knee Spine Surgery

D right foot/ankle D left foot/ankle D Cervical I O I Thoracic I 0 I LumbarOther Orthopedic Surgery

Non Orthopedic Surgeries Other Surgeries D abdominal surgery D hernlo repairD brain surgery D plastic surgeryD cancer surgery □ sinus surgeryD cardiothoracic surgery D tonsillectomyD eye surgery D urology surgeriesD gallbladder surgery D vascular surgeryD gynecologic surgery D other

8/6/2013 3

Patient Name: _DOB:------

DATE: _ MR#:·-----

SOCIAL HI STORY

Current Level of Exercise: Employment: Education: D Full Time D Grade School D do not regularly

exerciseD Part Time D High School/ D once per week

EquivalentD Retired D Some College D 3-5 times per weekD Student D College Degree D dailyD Unemployed D Graduate DegreeD Disabled

Alcohol: Tobacco: D Never use alcohol D I use chewing tobaccoD Used to drink but stopped D I have never smoked

tobaccoD Rarely drink alcohol D I used to smoke tobacco

(<1 /month) but stoppedD Drink occasionally D I currently smoke less than ½

(1-4/monthl pack per dayD Drink socially ( 1-2/week) D I currently smoke ½-1 pack

a dayD Drink frequently (3-5/week) D I currently smoke 1-2 packs

a dayD Drink daily ( 1 /day) D I currently smoke more than

2 packs a day

Drue s: Other druas: D Do not use drugsD cocaineD marijuanaD other

8/6/2013 4

Patient Name: _DOB:------

FAMILY MEDICAL HISTORY

DATE: _ MR#: -----

Please check all diseases for which vou have a family history: D Arthritis, Rheumatoid (inflammatory)D Arthritis, DegenerativeD Cancer - BreastD Cancer- ProstateD Cancer - OtherD DementiaD DiabetesD Heart DiseaseD High Blood PressureD High CholesterolD Lung DiseaseD StrokeD Other

Other diseases:

8/6/2013 5

Patient Name: _DOB:------

DATE: _ MR#: -----

MEDICATIONS AND ALLERGIES

Are you currently taking any medications?□ I Yes I□ I No

Patient Current Medications:Medication Name Dose For what purpose?

1234 5 6 7 8 9

1011 12

Do you have any allergies?□ I Yes I□ I No

Please list all allergies (includina iodine and contract dyes):Alleray Severity1 □ Mild □ Moderate □ Severe2 □ Mild □ Moderate □ Severe3 □ Mild □ Moderate □ Severe4 □ Mild □ Moderate □ Severe5 □ Mild □ Moderate □ Severe6 □ Mild □ Moderate □ Severe7 □ Mild □ Moderate □ Severe

8/6/2013 6

Patient Name: _DOB: ------

DATE: _ MR#:------

REVIEW OF SYSTEMS

General Eves ENT & Mouth Pulmonary (lunasl D none D none D none D noneD recent weight gain D difficulty D difficulty D shortness of breath

seeina hearinarecent weight loss D Loss of D nose bleeds D dry cough

D visionD appetite change D double D swallowing D productive cough

vision difficulty (sputum)D difficulty sleeping D blurred D Sinus D bronchitis

vision problemsD Fevers D asthmaD Problems walking D sleep apnea

(balanceproblems, fallinal

D Night sweats

8/6/2013 7

Patient Name: _ DOB· .

Gastrointestinal Genltourinarv Musculoskeletal Hematopoletlc/L vmohatlc □ No issues □ No issues D No issues □ No issues□ heartburn/ □ burning on urination □ joint pain □ anemia

inaestion□ difficulty □ frequency of □ joint deformity □ lymph node

swallowina urination enlaraement□ stomach pains □ difficulty starting □ joint swelling or □ frequent infections

urine warmth□ ulcers □ wetting pants or □ joint stiffness □ excessive bleeding

bed□ nausea/ □ bloody urine □ muscle pain □ blood clots

vomitina□ diarrhea □ sexual difficulties □ weakness

□ hemorrhoids □ neck pain

□ rectal bleeding □ back pain

□ black bowel Skin Neurologic movements

□ change in bowel □ No issues □ No issues Psychiatric habits

□ constipation □ ecchymotic □ headaches □ No issues□ frequent laxative □ purulent drainage □ dizziness □ anxiety

use (pus)

□ jaundice or □ swollen □ blackouts □ depressionhepatitis

□ liver trouble □ Erythematous (red) □ numbness and □ difficulty sleepingtinalina

□ gallbladder □ rash □ paralysis □ appetite changesproblems

□ itching □ convulsion/seizur □ confusiones

□ easy □ coordination □ memory lossbruisina/bleedina trouble

□ slow healing □ been seen by apsychiatrist

Endocrine/Metabolic Cardiovascular □ No issues □ No issues □ leg cramps (when walking)

□ diabetes □ high blood pressure □ fainting

□ goiter □ chest pain □ coldness in hands and/or feet

□ thyroid problem □ heart attack □ loss of hair on arms or legs

□ sterility □ palpitations (irregular heart beat) □ abnormal color (blue, white, red) inhands or feet

□ cholesterol / lipid □ heart failure □ otheroroblem

□ edema (leg swelling)

DATE: _ MR#·

8/6/2013 8

Patient Name: --------- DOB: ------

GENERAL NEW PATIENT HISTORY

CURRENT INJURY /PROBLEM

DATE: _ MR#: -----

What is the MAIN injury/problem you are seeing the doctor for today? IF UNLISTED CHOOSE THE CLOSEST. □ right shoulder □ left shoulder □ head□ right arm □ left arm □ neck□ right elbow □ left elbow □ chest□ right forearm □ left forearm □ midback□ right wrist/hand □ left wrist/hand □ low back□ right hip □ left hip □ Problems walking0 right thigh □ left leg □ Weakness,

numbness, tinglinq□ right knee □ left knee □ Other□ right calf □ left calf□ right foot/ankle □ left foot/ankle

If more than one injury /problem, which is worse? SELECT ONLY ONE - IF UNLISTED CHOOSE THE CLOSEST. □ right shoulder □ left shoulder □ head□ right arm □ left arm □ neck□ right elbow □ left elbow □ chest□ right forearm □ left forearm □ midback□ right wrist/hand □ left wrist/hand □ low back□ right hip □ left hip □ Problems walking□ right thigh □ left thigh □ Weakness,

numbness, tinglina□ right knee □ left knee □ Other□ right calf □ left calf□ right foot/ankle □ left foot/ankle

Date lnlu / roblem be an APPROXIMATE IF UNSURE:

Is vour oroblem a result of an injury /problem? □ Yes□ No

8/6/2013 9

Patient Name: _DOB: ------

DATE: _ MR#:-----

Please describe your current problem. IF YOU ARE SEEING THE PROVIDER FOR MULTIPLE PROBLEMS, ANSWER FOR THE MOST SEVERE:

□ New injury or problem (less than 6 weeks duration)□ Sub-acute problem (6 week- 3 months duration)□ Chronic problem (problem has been treated over time period of

more than 3 months and never been restored to normal)□ Re-injury

What caused your injury /problem? Other cause of injury /problem: □ Fall□ Lifting□ Throwing□ Reaching□ Pulling□ Fighting□ Twisting□ Sports□ Collision/ContactD Other

If the problem/injury is a result of an Other: iniurv, where did it occur?

□ at home□ at work□ via a motor vehicle accidentD while exercising□ at a sport competition□ other

Check any of the following that happened at the time of your iniurv /problern: □ Felt pain □ Had swelling □ Fracture □ I Bruising□ Heard popping □ Dislocation D Deformity

Have you had surgery related to the problem you are being seen for today?

□ Yes□ No

8/6/2013 10

Patient Name: _DOB· .What conservative treatment have you had on or since your lnlurv/problern began? D Injection D Chiropractic careD Aspiration D BracingD Physical Therapy D HeatD Exercise D IceD Anti-inflammatory medication D MassageD Pain medication D Rest

Date you began conservative treatment

DATE: _ MR#·

Have you received non-surgical Are you receiving or have you treatment for at least 3 months for this applied for worker compensation problem? concerning your problem/injury? D Yes D YesD No D No

Have you talked to a lawyer Is your problem the result of an concerning your problem/injury auto accident? D Yes D YesD No D No

PAIN

o continuous/constant

4 D 5 D 6 D 7 D 8 D 9 D 10

D never occasionally D frequently

What time of day is Check the words that best describe the character vour oain worst? of the oain vou are havlna today: □ morning D aching D nagging D shooting□ afternoon D burning D numb D tender□ evening D exhausting D throbbing D unbearable□ nighttime D gnawing D sharp□ all the time □ miserable D stabbing

8/6/2013 11

Patient Name: _DOB: ------

DATE: _ MR#:·------

Other factor that What makes your symptoms better? makes the pain

better: □ rest □ sittina □ sports/exercise□ medication □ standina □ brace/cane/crutch□ ice □ walkina □ sleeolno□ heat □ sauattinq D physical theraov□ lvina down □ stretchina □ iniection

□ nothing inparticular

Other factor that What makes your svmotoms worse? makes the pain worse: □ lying down D stooping/ □ pushing

bendina□ sittina D liftina □ oullino□ stcndlno □ souottlno □ worklno□ walking □ stairs □ nothing in

particular□ sports/ D reaching

exercislno□ twisting/pivoting □ overhead

activity□ activity in

oenerol

8/6/2013 12

Patient Name: ---------- DOB:------

DATE: _ MR#: -----

PREFRERRED PHARMACY INFORMATION

Pharmacy Name

Pharmacy Street Address

City, State, Zip

If address unknown please provide crossroads

Pharmacy Phone Number

Everything I have answered is true and correct to the best of my knowledge.

Patient Signature: Date: _

8/6/2013 13