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right258445REASON FOR TODAY’S VISIT0REASON FOR TODAY’S VISITProblem (s) :________________________________________________________When did the problem begin? __/___/____ □Injury □Sudden Onset □Gradual OnsetPlease Mark the area(s) of pain/ discomfort/ injury: □ Right □ Left □ Bilateral10058401030605R00R9505952250440R00R2457452231390L00L2076451002665L00LHow did the problem develop? __________________________________________________□ Over Use □ Lump/ mass □ Weakness □ Loss of sensation □ Unknown□ Fall □ Crush □ Cut/Laceration □ Puncture/ Bite □ Twisting Injury □ BurnYour pain/ discomfort level Today is _____ /10 (0= no pain, 10= worst pain)Your Worst pain/ discomfort is ______/ 10What symptoms do you have? □ Pain □ Numbness/Tingling □ Weakness □ Burning □ Popping □ Locking □ Aching □ Throbbing □ Swelling □ Skin Changes □ Other:When is your pain/ discomfort worse? □ With Use □ Morning □ Night □ At All Times□ Driving □ Lifting □ Gripping □ Pinching □ Other:____________________________Does the problem wake you up at night? □ Yes □ NoWhat helps the problem? □ Rest □ Brace/splint □ Heat/Cold □ Shaking limb □ Other:□ Medication(s): ________________________________________ □ Nothing helpsWho else have you seen for this probem?____________________ When? ___________What treatment(s) have you had? ____________________________________________Prior injuries of the upper extremities: What?_______________ When? ___________Do you have problems with your: □ Shoulders □ Neck □ Back □ Hips □ Knees □ Feet0-7456170REASON FOR TODAY’S VISIT0REASON FOR TODAY’S VISIT0189230SOCIAL HISTORY0SOCIAL HISTORYOccupation: _______________________________________□ Retired □ Student □ Disabled□ Currently Working (full / part time) □ Not Working Last Day Working: ___/ ___/ ______What activities do you do at work?_______________________________________________Recreational activities/ hobbies?_______________________________ Frequency?________Do you use tobacco? □ No □Year Quit:___ □ Yes (Smoke/ Chew) Packs/Day:____ Years:___ Alcohol use? □ No □ Yes Drinks/week:_____ Marijuana use? □ No □ Yes Frequency:_____right346710REVIEW OF SYSTEMS: Do you currently have or have you ever experienced problems with the following medical conditions:00REVIEW OF SYSTEMS: Do you currently have or have you ever experienced problems with the following medical conditions:Other Drug use: ________________ □Current user □ Former User □ In Recovery NoCurrentPastFamilyExplanationEye ProblemsEar, Nose, and throat problemsCardiovascular DiseaseRespiratory Disease Asthma, Sleep Apnea-Do you snore?-Has anyone observed you stop breathing while sleeping? N N Y YGastrointestinal ProblemsMusculoskeletal disease Arthritis, lupus, RheumatoidSkin ProblemsBrain or nerve disordersBleeding disordersThyroid ProblemsLiver DiseaseSerious Infection HIV, Hepatitis, MRSA, etcPsychiatric conditions Depression, etcCancerAdverse reaction to AnesthesiaOther: left192405PAST MEDICAL HISTORY0PAST MEDICAL HISTORYPlease list any past surgeries and the Dates:●Procedure:_________________Year:____ ● Procedure:_________________Year:____ ●Procedure:_________________Year:____ ● Procedure:_________________Year:____ ●Procedure:_________________Year:____ ● Procedure:_________________Year:____ Please list any Allergies you have and type of reaction:●_________________________________ ●____________________________________ ●_________________________________ ●____________________________________Please list all current medications and the dosage:● Medication: ___________________________ Dose (mg): _______ Times per day: _______● Medication: ___________________________ Dose (mg): _______ Times per day: _______● Medication: ___________________________ Dose (mg): _______ Times per day: _______● Medication: ___________________________ Dose (mg): _______ Times per day: _______● Medication: ___________________________ Dose (mg): _______ Times per day: _______● Medication: ___________________________ Dose (mg): _______ Times per day: _______I am… □ Right Hand Dominant □ Left Hand Dominant □ AmbidextrousSign: ____________________________________________ Date: ___________________right189230CURRENT VITALS0CURRENT VITALS[To be completed by office staff:]Vitals…. Ht:_______ Wt:_____ BP:____/_____ HR:_____ Resp:______ Temp:_____ Grip Testing: Right:____lbs Left:_____lbs Pinch Testing: Right:____lbs Left:_____ lbs ................
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