History Form
James W. Vahey, MD [pic] George S. Gluck, MD
HAND CENTER OF NEVADA: Comprehensive Upper Extremity Care from Hand to Shoulder
1. Name: ________________________________________________________ 2. Age:_______
3. Which part(s) of your arm are problematic for you?(check boxes)
Shoulder Elbow Forearm Wrist Hand Finger
(Right (Right (Right (Right (Right (Right ( ((thumb (index (long (ring (small)
(Left (Left (Left (Left (Left (Left ( ((thumb (index (long (ring (small)
4. Which hand do you write with? (Right (Left
5. Occupation:_______________________________6.Employer:__________________________________
7. Work Status: ( Full Duty ( Light Duty (Not Working (Retired
8. Referred by(Doctor, Family/Friend, Internet, Advertisiment)(Name?):______________________________
9. Date of injury or duration of problem:_______________________________________________________
-If you were injured, where did the injury occur?
(Work (Home (School (Sports (Car Accident (Other_____________________________________
-How have your symptoms changed over time? (Better (Unchanged (Worse
10. Are you planning to file, or currently involved in, a lawsuit regarding your injury? (Yes (No
11. If know, describe how did your problem started:________________________________________________
12. On a scale of 0 (no pain) to 10 (the most pain), please circle your AVERAGE pain:
0 1 2 3 4 5 6 7 8 9 10
ϑ Κ Λ
Do you have night pain? (Yes (No --If yes, circle how many nights it wakes you each week? 1 2 3 4 5 6 7
13. Describe your pain/symptoms.(Mark all that apply.)
(Sharp (Dull (Throbbing (Stabbing (Burning (Shooting/Radiating (Numbness/Tingling
(Weakness (Stiffness (Swelling (Other________________
14. What treatment(s) have you had for this problem?(Mark all that apply.)
(Medication (Injection (Brace/cast (Therapy (Surgery (Other________________________________
15. Did any treatment help?(Which ones?)______________________________________________________
16. List current medications/dosages if known or provide separate sheet.(include Aspirin, Vitamins, etc)
_________________________________________________________________________________________
________________________________________________________________________________________
17. List drug or latex allergies and reaction (i.e. Penicillin, Sulfa, Latex / rash, hives, throat swelling)
18. Medical History(MARK HERE ( IF "NONE")
(Anxiety (Cubital Tunnel (High Blood Pressure (Stroke
(Asthma/Allergies (Depression (High Cholesterol (Sleep Apnea
(Anemia (Diabetes (Joint Problems/Arthritis (Thyroid Disease
(Blood Clots (GERD/Stomach ulcers (Kidney Disease (Pacemaker
(Bursitis (Gout (Neck/Back Problems (Prostate problems
(Cancer (Glaucoma (Seizure Disorder (Substance Abuse
(Carpal Tunnel (Heart Disease/MI (Scleroderma Other: _______________
19. Surgical History (MARK HERE ( IF "NONE")
( Arm, Leg, or Back Surgeries(include dates)_________________________________________________________
(Tonsils Removed (Appendix Removed (Hysterectomy (Gall Bladder Removed (C-Section (Hernia Repair
(Other____________________________________________________________________________________
20. Family History(Grandparents, Mother/Father, Siblings)
(Asthma (Dupuytren’s Disease (Other_______________________
(Arthritis (Heart Disease/MI
(Cancer (High Blood Pressure
(Depression (Kidney Disease
(Diabetes (Osteoporosis
21. Social History
Tobacco use: (No (Yes (Quit Packs per day?_______
Alcohol use: (No (Yes Amount/Frequency?__________
Hobbies/Interests(i.e. golf/sports, knitting, TV, etc)?________________________________________________
Activity Level – How many times a week do you exercise?_________
Marital Status: (Single (In Relationship (Married (Divorced/Separated (Widowed
# of children?___ # of people living with you at home?____
22. Symptoms you currently have (MARK HERE ( IF "NONE")
HEENT Constitutional Respiratory GI
( Headaches ( Weight gain ( Shortness of breath ( Loss of appetite
( Nose bleeds ( Weight loss ( Cough ( Nausea/Vomiting
( Hearing Loss ( Fever ( Wheezing ( Diarrhea
( Ringing in ears ( Fatigue ( Exposure to TB ( Bloody/dark stool
( Vertigo/Dizziness ( Chills ( Abdominal pain
( Difficulty swallowing ( Night sweats ( Heartburn/reflux
( Double vision ( Constipation
( Bleeding gums ( Ulcers
( Dental pain
Cardiovascular Genitourinary Dermatological
( Chest pain ( Urinary frequency/retention ( Contact/metal allergy
( Palpitations ( Blood in urine ( Rashes
( Lightheaded/Fainting spells ( Frequent night-time urination ( Blisters
( Incontinence ( Skin ulcers
Neurological Hematologic Endocrine
( Seizures/Tremors ( Easy bleeding/bruising ( Cold intolerance
( Anxiety ( Blood clots ( Heat intolerance
( Loss of coordination/balance ( Previous blood transfusions ( Low blood sugar
( Difficulty walking ( Low blood count/anemia
( Memory loss
( Depression
_________________________________________
James W. Vahey, MD / George S. Gluck, MD
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