NEW PATIENT INFORMATION

Date ______

Name ______Age ______Birth Date ____/____/____
Home Phone (______)______, Business (______)______

Address ______

City ______State ______Zip ______

Referring Doctor ______

Address ______

City ______State ______Zip ______

Primary Care Doctor______

Address ______

City ______State ______Zip ______

Occupation ______Sports ______

Are you currently working? Yes______No______If no, how long have you been out of work? ______

If your problem involves an injury or time loss from work: Date of injury: _____/_____/_____

Last day worked: _____/_____/_____ Is this an industrial injury? Yes_____ No_____

Labor and Industry (L&I) Claim Number: ______

Insurance: Private, State L&I, Federal Workman’s Compensation, DSHS, Other______

HISTORY OF PRESENT ILLNESS: For the problem that brings you to the office today (circle one or describe in your own words):

Please describe the problem that you would like help with: ______

______

1. Duration of pain, numbness, instability, or other: When did this problem begin? ______

2. Please describe the exact location of your problem as best you can ______

Where is your Pain? On the diagram, shade the areas where you have the most pain. Put an X on the area that hurts the most.

  1. Please describe the quality of your symptoms: Numbness, Instability of a joint, Pain, Other ______
  1. Is your pain control a problem for you? Yes_____ No_____
  2. Circle a word(s) that describes your pain.

4. Please describe the severity of your symptoms: Please use the scale of numbers on the right to describe how bad your pain or other symptoms are:

5. Please describe the timing of your symptoms: daytime or nighttime, other? ______

6. In what context do your symptoms occur in relationship to activities, work, recreation, other? ______

7. What do you do to decrease or modify your pain or other symptoms? (wear a splint, take anti-inflammatory medication, use heat, use cold) ______

  1. What signs or symptoms are associated with your symptoms? ______
  2. Do you want to talk to your health care provider about your pain today? Yes____ No_____

Please list any medications you take this problem: ______

For the problems that brings you to the office today:

What past surgeries have you had (where, when, with what surgeon, and did they help?)

______

What studies have you had and what did they show?

MRI? ______

Bone Scan? ______

Arthrogram? ______

CT Scan? ______

EMG/NCV? ______

Other? ______

REVIEW OF SYSTEMS

Have you ever had one or more of the problems related to: (circle one or describe in your own words):

  1. Constitutional (Fatigue) No___ Yes ______
  2. Eyes No___ Yes ______Ear, Nose, Throat No___ Yes ______
  3. Cardiovascular (Hypertension, Heart Attack, Angina, Heart Murmur No___ Yes ______
  4. Respiratory (Asthma, TB, Emphysema, Bronchitis) No___ Yes ______
  5. Gastrointestinal (Ulcers, Hepatitis, Heartburn) No___ Yes ______
  6. Genito-urinary (Kidney Stones, Kidney Infections, Prostate Problems) No___ Yes ______
  7. Musculoskeletal (Arthritis, Fractures, Sprains) No___ Yes ______
  8. Skin: (dermatitis, psoriasis) No___ Yes______
  9. Neurologic (Seizures, Strokes, Severe Headaches, No___ Yes______
  10. Psychiatric, Anxiety, Depression, Other______
  11. Endocrine (Diabetes, Thyroid Disorder)______
  12. Hematological (Bleeding Disorders, Clotting Disorder)______
  13. Imnunological (Hay Fever) No___ Yes ______

FAMILY HISTORY; Medical conditions that run in your family (Please circle or add in your own description including the family members involved)

  1. Heart attacks? ______
  2. Strokes? ______
  3. Kidney disorders? ______
  4. Arthritis (rheumatoid?, osteoarthritis? ______
  5. Diabetes? ______
  6. Cancer? ______
  7. Hypertension? ______
  8. Depression or other psychiatric illnesses? ______
  9. Other? ______

Past Surgeries (Excluding surgeries for the problem that brings you into the office today):

1. ______

2. ______

3. ______

4. ______

What medications do you take (prescription and non-prescription)?

Medication? /

Dosage?

Are you allergic to any medications or medical substances? If so, please list:

Medication / Reaction

Social History:

Married: Yes ____ No ____ Other Relationship ______Children: No ____ Yes ____ # ______

Do you smoke? Yes _____ No_____ How many packs per week? ______

Do you consume alcohol? Yes_____ No_____ How many glasses-bottles/week? ______

Do you now have or have you ever had a chemical dependency? Yes_____ No_____

Any intravenous drug use? Yes_____ No_____

Examination:

Skin: NL  abnormal (circle one) sweat, color, capillary refill) other? ______

Neurologic: Gait NL  Abnormal  Reflexes

Reflex / Right / Left

Triceps

Biceps
Brachioradialis
Quadriceps
Tendoachilles

Strength (Motor Testing)

APB

/ Right / Left
Intrinsics

Shoulder Abduction

Other

Grip Strength (Kilograms) Jamar Dynometer

Setting

/ Right / Left
I

II

III
IV
V

Sensation (Semmes-Weinstein (S-W) monofilaments and /or 2-point testing (2 pt)

Finger

/ Right S-W / Right 2 pt / Left S-W / Left 2 pt
Thumb (T)
Index finger(IF)

Middle Finger (MF)

Ring Finger (RF)
Small Finger (SF)

Wrist Range of Motion

Side / Right /

Left

Flexion
Extension
Radial Deviation (RD)
Ulnar Deviation (RD)

Finger Range of Motion

Right------Left------

Digit / MP / PIP / DIP / MP / PIP / DIP
Thumb / ------ / ------
Index
Middle
Ring
Small

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