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Patient Name: ___________________________ Age: _______ Height: ________ Weight: ________ Email:__________________________ Cell Phone:______________________________Were you referred by another physician? _________________________ PCP: _____________________313800814927900If not, how did you hear about us? _______________________________________________________SPECIFY YOUR SYMPTOMATIC AREA:Check all that applyLeftRightBothKneeHipLow BackShoulderOtherWhat number on the scale (0-10)…Was the pain less severe 2 years ago? __Y / N__best describes your pain right now? ______ best describes your worst pain? _____ SYMPTOMS (Please circle those that apply)best describes your least pain? ______Aching Cramping Soreness Stiffness Numbness Tingling BurningPopping Crunching Giving way Pain at rest Pain at Night Pain with Activities Pain with getting out of a chair OTHER:________________________The pain began? __________ (DAYS / WEEKS/ MONTHS/ YEARS)How did it begin: GRADUALLY / SUDDENLYSince your pain began, has it (DECREASED / INCREASED / REMAINED THE SAME)?Is this from a prior injury? (YES/NO) What is the date of injury ___/___/_____ Motor vehicle accident / work related / sports / slip or fallPAIN LOCATIONKNEE Patients: FrontKnee capJoint lineBack of the kneeHIP Patients: Groin Side Buttock Thigh Does your pain radiate? YES / NO: If so, where to? _________________Circle all of the following activities that are adversely/negatively affected by pain:Lying downSitting WalkingRunning LiftingSleepingStanding Intercourse Coughing Exercising The Pain is Improved By… Circle all that apply:RestWalkingAcupuncture Chiropractic Massage TENS Unit Joint Injections IceHeat Exercising Elevation Muscle Relaxers Assistive Device ImmobilizationDo you have a Limp? Circle all that apply: None Slight Moderate SevereUnable to walkDo you Use Assistive Devices? Circle all that apply: None Occasional Cane Cane, full time Crutches walker Distance walked? Circle all that apply: Unlimited 2-3 blocks Indoors only Bed to chair Bedbound FUNCTIONDoes your condition limit?Putting on socks and shoes YesNoHome choresYesNoStairsYesNoSelf-care: Dressing / BathingYesNoToiletingYesNoExerciseYesNoWorkYesNoPREVIOUS TREATMENTS FOR THIS JOINT (please circle the ones that you’ve had)Over-the-counter anti-inflammatory medication such as Ibuprofen/Advil/Aleve/MotrinPrescription anti-inflammatory (for example: Celebrex/Mobic/Naproxen/Other)Pain medications (for example Tylenol, Ultram, Hydrocodone, other Narcotics)Cortisone-type injection in the joint – When? ______ Doctor? ____________________Joint lubricant (“rooster comb”) injection - When? ______ Doctor? _______________Physical Therapy -- If yes, how long? _________________ did it help? ____________ – If no, do you think it would hurt too much? _______Home Exercise ProgramBracePREVIOUS STUDIES Circle all that apply:X-RAYS CT SCAN MRIEMG/NCVBONE SCANDEXA SCANVIT D LEVEL MEDICATIONS: Please list your current prescribed medications and over the counter medications and supplements_____ I am NOT currently taking any medications.Please indicate which (if any) of the following BLOOD THINNERS you are taking?? Aggrenox ? Aspirin ? Coumadin ? Effient ? Eliquis ? Lovenox ? Plavix ? Pletal ? Pradaxa ? Ticlid ? Xarelto ? WarfarinMedication/DosageReason for usePAST MEDICAL PROBLEMS: Please review the ongoing medical problems, past major illnesses, and hospitalizations below and check the ones that apply to you.____ Abnormal heart rhythm ____ Degenerative arthritis ____ Migraines – chronic ____ Anemia ____ Depression ____ Miscarriages – chronic ____ Angina ____ Diabetes Mellitus ____HbA1C____ Neuropathy ____ Anxiety ____ Diarrhea – chronic ____ Obesity ____ Aortic stenosis ____ Dialysis____ Enlarged prostate / BPH ____ Osteoarthritis ____ Asthma ____ Fibromyalgia ____ Osteoporosis ____ Back pain – chronic ____ Gout ____ Pneumonia – chronic ____ Bipolar disorder ____ Heart attack ____ Poor circulation____ Birth Control____ Excessive Bleeding disorder ____ Heart disease ____ Protein in urine – chronic ____ Bleeding tendency ____ Heart murmur ____ Psoriasis ____ Blood clots ____ Heart stent ____ Pulmonary embolism – chronic ____ Cancer – Brain ____ Hepatitis A ____ Reflux ____ Cancer – Breast ____ Hepatitis B ____ Rheumatoid arthritis ____ Cancer – Cervix ____ Hepatitis C ____ Seizure – chronic ____ Cancer – Colon ____ Hiatal hernia ____ Sexual difficulty ____ Cancer – Kidney ____ High blood pressure ____ Hormone replacement ____ Sinus Allergies ____ Cancer – Lung ____ High cholesterol ____ Sleep apnea ____ Cancer – Ovary ____ HIV ____ Stomach ulcers ____ Cancer – Prostate ____ Hyperthyroidism ____ Stroke ____ Cancer – Skin – Melanoma ____ Hypothyroidism ____ Tuberculosis exposure ____ Cancer – Thyroid ____ Irritable bowel syndrome ____ Urinary tract infections____ Chest pain ____ Kidney infection – chronic ____ Varicose veins ____ Cirrhosis ____ Kidney stones – chronic ____ Tremors/Parkinson____ Congestive heart failure ____ Low platelets ____ Paralysis____ Constipation – chronic ____ Low white cell count ____ COBP / Emphysema ____ Lupus ____ Coronary artery disease ____ Menstrual problems Additional medical problems: __________________________________________________________________________.ALLERGIES: _____ I am NOT allergic to any medications.ALLERGYREACTIONPenicillin ? Rash ?airway closing off?other_____________Sulfa? Rash ?airway closing off?other_____________Latex? Rash ?airway closing off?other_____________IV Iodine? Rash ?airway closing off?other_____________Topical Iodine? Rash ?airway closing off?other_____________? Rash ?airway closing off?other_____________PAST SURGICAL PROCEDURES: Please review the procedures listed below and check the ones that apply to you.____ Abdominal surgery ____ Hernia surgery ____ Sleep apnea surgery ____ Amputation ____ Hip replacement ____ Spine surgery – Cervical (Neck)____ Angioplasty / (Heart Stents)____ Hysterectomy ____ Spine surgery – Lumbar (low back)____ Aorto-femoral bypass ____ Hysterectomy – partial ____ Spine surgery – Thoracic(mid back)____ Appendectomy ____ Interventional pain procedures ____ Thyroidectomy (taking out thyroid)____ Bronchoscopy ____ Nephrectomy (Kidney removal) ____ Tonsillectomy (taking out tonsils)____ CABG / Heart bypass ____ Kidney transplant ____ Tunneled dialysis catheter ____ Carotid endarterectomy ____ Knee arthroscopy ____ TURP ____ Carpal tunnel release ____ Knee replacement ____ Urinary incontinence surgery ____ Cataract surgery ____ Kyphoplasty ____ Vasectomy ____ Colon resection ____ Liver transplant ____ Vertebroplasty ____ Craniotomy ____ Mastectomy ____ Anesthesia complications ____ C-Section ____ Mitral valve replacement ____ Surgical complications ____ Dilation and curettage ____ Pacemaker ____ Post-operative delirium ____ Femoral bypass ____ Par thyroidectomy ____ Organ transplant____ Fracture repair ____ Prostatectomy Additional Surgeries: ____ Gallbladder removal ____ PTCA _________________________________ Gastric surgery ____ Rotator cuff repair _____________________________ ____ Heart valve replacement ____ Shoulder arthroscopy _____________________________ ____ Hemorrhoidectomy ____ Shoulder replacement ____ I have not had any surgical procedures. FAMILY HISTORY: Is your family member Living (L) or Deceased (D)?Mother ____ L ____ D Father ____ L ____ D Siblings ____ L ____ D Children ____ L ____ DDo any of the following diseases run in your family? If so please check the diseases that do.MotherFatherSiblingsChildrenHigh Blood PressureKidney DiseaseHeart Disease / heart AttackCancer / TypeStrokeBleeding DisordersSeizuresDiabetesThyroid DiseaseMental IllnessOtherSOCIAL HISTORY:Do you drink alcohol? _____ YES _____ NO _____ OCCASIONALLY how many per week: __________Tobacco Usage: Do you currently smoke or use other forms of tobacco?____ Current everyday smoker ____ Current someday smoker ____ Former Smoker ____ I have never smokedREVIEW OF SYSTEMS: Please review the systems below and select your CURRENT symptoms.GENERAL:EAR, NOSE, AND THROATCARDIOVASCULAR:____ weight loss - abnormal____ sore throat ____ chest pain____ weight gain -abnormal____ sinus pain ____ swelling in hands and feet____ fever____ decreased hearing ____ irregular heartbeat____ chills____ nose bleeds____ heart problems____ night sweats ____ hoarseness____ difficulty lying flatRESPIRATORY:GASTROINTESTINAL:GENITOURINARY/URINARY: ____ wheezing____ abdominal pain____ kidney problems____ cough____ constipation____ blood in urine____ shortness of breath____ diarrhea____ painful urination____ coughing blood____ vomiting____ difficulty urinating____ sputum production____ rectal bleeding____ frequent urination____ heartburnMUSCULOSKELETAL:SKIN:NEUROLOGIC:____ joint pain____ rash____ headaches____ back pain____ itching____ stroke____ muscle aches____ skin oozing____ paralysis____ limp ____ blistering of skin____ dizziness____ sciatica____ skin lesions____ numbness/tinglingPSYCHIATRIC: ENDOCRINE:HEMATOLOGY:____ anxiety ____ irregular menses____ bleeding easy____ depression ____ excessive sweating____ easy bruising____ psychiatric condition____ excessive thirst____ family with bleeding problems____ suicidal thoughts____ cold intolerance____ swollen glands____ substance abuse____ weakness____ breast lumpOTHER:____ Resistant staphylococcus MRSA____ Rheumatoid ____ pulmonary embolism____ Chronic infection____ Hepatitis A - B - C____ Blood clots____ History of smoking____ HIV____ Factor V/VIII deficiencies____ Dialysis____ Von Willebrand Disease (VWD)____ Organ Transplant____ (HRT) Hormone Replacement ................
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