PDF Musculoskeletal History - check all that apply to you

[Pages:5]Name________________________________________________ Date ___/___/_______ Clinical Intake Form

Past Medical History- check all that apply to you

___ Anemia ___ Anxiety ___ Asthma ___ Atrial fibrillation ___ Bipolar disorder ___ Breast cancer ___ Cardiac; hyperlipidemia ___ Cardiac; heart disease ___ Chronic pain

___Colon cancer ___ COPD

___ Coronary artery disease ___ D V T ___ None of the above

___ Depression ___ Diabetes; insulin ___ Diabetes; no insulin ___ End stage renal disease ___ GERD ___ Hepatitis ___HIV/AIDS ___ Hypercholesterolemia ___ Hyperparathyroidism

___ Hypertension ___ Hyperthyroidism ___ Hypothyroidism ___ Leukemia ___ Lung cancer

___ Lymphoma ___ Multiple myeloma ___ Obesity ___ BPH (enlarged prostate) ___ Prostate cancer ___ Pulmonary embolus ___ Radiation therapy ___ Rheum: Fibromyalgia ___ Rheumatoid arthritis

___ Sleep apnea ___ Seizures

___ Stroke ___ Other

Past Surgical History- check all that apply to you

___ Appendectomy

___ Breast lumpectomy/mastectomy left right bilateral

___ Breast implants reduction

___ Colectomy Cancer Diverticulitis Other bowel disease

___ Colostomy

___Gallbladder (cholecystesctomy)

___ None of the above

___ Gastric bypass band reduction sleeve

___ Heart coronary bypass valve:biologic/mechanic PTCA: angioplasty/stent Transplant

___ Kidney stone nephrectomy L R transplant L R

___ Liver transplant other surgery

___ Prostate

___ Rectum APR(anterior posterior) Low anterior

___ Skin Basal cell Squamous cell Melanoma

___ Tonsillectomy

___ Ovaries removed ovarian cancer

___ Pancreas

___ Uterus hysterectomy C section uterine Ca cervical Ca

___ Other

Last menstrual period ____/____/________

Are you pregnant yes no don't know

1

Musculoskeletal History - check all that apply to you

___ Ankle fracture L R ___ Ankylosing Spondylitis ___ Adhesive capsulitis L R ___ Bursitis L R ___ Carpal tunnel synd L R ___ Chronic back pain ___ DISH ___ Radius fracture L R ___ Epidural spine injection

___ Fracture(broken bone) ___ Gout ___ Handedness ambi L R ___ None of the above

___ Hip fracture

L R

___ HNP cervical

___ HNP lumbar

___ Metastatic bone disease

___ Osteoarthritis (DJD)

___ Osteopenia ___ Osteoporosis ___ Polio

___ Primary bone sarcoma

___ Psoriatic arthritis ___ Rheumatoid arthritis ___ Rickets

___ RSD

___ Sciatica ___ Scoliosis ___ Shoulder impingement ___ Spine fracture ___ Soft tissue sarcoma ___ Spinal stenosis, cervical ___ Spinal stenosis, T/lumbar ___ Vertebral compression

fracture ___ Vitamin D deficiency ___ Wrist fracture ___ Other

Musculoskeletal Surgery- check all that apply to you

___ Achilles repair

L R ___ Total hip

L R ___ Meniscus repair L R

___ ACL reconstruction L R

___ Ankle fracture ORIF L R

___ Bunion surgery

L R

___ Carpal tunnel surg L R

___ C spine fusion

___ C spine disc replacement

___ CMC arthroplasty L R ___ Distal radius ORIF L R

___ Ganglion cyst

L R

___ Femur fracture ORIF L R ___ Tibia fracture ORIF L R ___ Arm fracture ORIF L R ___ None of the above

___ Total knee

L R

___ Total shoulder L R

___ Knee arthroscopy L R

___ Kypho/vertebrplasty

___ Lumbar fusion

___ Lumbar laminectomy

___ Lumbar decompression ___ Lumbar decompression

and fusion ___ Lumbar disc replacement

___ Reverse shoulder L R ___ Revision hip surg L R ___ Revision knee L R ___ Revision shoulder L R ___ Rotator cuff surg L R ___ Shoulder arthroscopy

L R ___ Trigger finger L R ___ Other

2

Family History- check all that apply to you

Charcot Marie Tooth Diabetes Hypertension Multiple Hereditary Exostosis (Olliers) Osteoarhritis Osteoporosis Rheumatism Scolio Scoliosis Other

Mother Father Sister Brother Daughter Son Other

___ None of the above

Interventional Pain History- check all that apply to you

___ ESI

Cerv Thor Lumb

___ Facet inj Cerv Thor Lumb

___ Intrathecal pump ___ None of the above

___ Medial branch block Cerv Thor Lumb

___ Rhizotomy Cerv Thor Lumb

___ Spinal cord stimulator ___ Other

3

Medicines Please list ALL current medications or check the option which applies

___ I brought a medicine list that included name, dosage, and how I take it ___ I am not taking any medications

Medication Name

Dosage

How and how often do you take it

Allergies Please list ALL allergies or check option which applies

___ I brought an allergy list that includes the allergen name and my reaction to it ___ I have No known allergies

Allergy

Describe allergic reaction, severity, and symptoms

Social History

Cigarette smoking ___ Never ever ___ Quit, when______________ ___ Less than daily ___ Daily # packs/day _________ years smoked_____

Alcohol Use ___ Never ever ___ Quit, when______________ ___ Less than 1 drink/day ___ 1-2 drinks/day ___ 3 or more drinks/day

Exercise Frequency ___ Never ever ___ Several times/day ___ Once a day ___ Few times/week ___ few times/month ___ other

4

Why are you being seen today? Include what, when, where, and who

On the job? Y N Auto accident? Y N Adjustor________________________________ Any other orthopedic problems? Pharmacy: Name and location

Doctors:

Name

Referring:

Primary:

Other docs: Name

Location Location

What are they treating?

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