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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