Ortho New Patient Medical History Questionnaire (PDF)

UF Orthopaedics & Sports Medicine Institute
Patient Name :
Date : MRN :
Referring Physician :
Date of Injury :
Primary Care Physician :
General : Male Female
Age : Date of Birth :
Race :
Pharmacy :
Caucasian African-American Hispanic
Asian
Other
Medical History Yes No Yes No Yes No
Allergies------------------------------------ Lung Disease---------------- Meningitis--------------------------------
Anemia--------------------------------------
Depression---------------------
Nerve / muscle disease--------------
Anxiety--------------------------------------
Diabetes Mellitus-------------
Osteoporosis----------------------------
Arthritis-------------------------------------- Acid Reflux-------------------- Seizures----------------------------------
Asthma-------------------------------------- Glaucoma---------------------- Sickle Cell--------------------------------
Blood Transfusion------------------------ Gout----------------------------- Stroke-------------------------------------
Cancer--------------------------------------
Heart Attack-------------------
Substance Abuse----------------------
Cataracts-----------------------------------
HIV/AIDS-----------------------
Thyroid Disease------------------------
Congestive Heart Failure---------------
Kidney Disease---------------
Tuberculosis-----------------------------
Clotting disorder (i.e., blood clot)----- High Cholesterol------------ Ulcers-------------------------------------
High Blood Pressure-------------------
Anesthetic Complications------------
Any Other Medical History:
Pharmacy Address :
Female Patients Only
Adults
Irregular periods
Frequent spotting
Are you pregnant?
Yes
Yes
Yes
No
No
No
Are you nursing? Yes No
Female Menstrual History (Females over age 10)
Have you started your periods? Yes No
When was your last period?
If yes, at what age?
Surgical History Yes No Yes No Yes No
Appendix---------------------------------- Cosmetic surgery------------- Joint replacement-----------------------
Brain surgery-----------------------------
C-Section------------------------
Small intestine surgery----------------
Breast surgery----------------------------
Eye surgery---------------------
Spine surgery----------------------------
Open Heart or Bypass----------------- Fracture surgery -------------- Tubes Tied-------------------------------
Gall Bladder-------------------------------
Hernia repair-------------------
Valve replacement---------------------
Colon Surgery-----------------------------
Hysterectomy-------------------
Occupation
Are you a Student
Occupation
Any Other Surgical History:
Yes
No
Are you Retired Yes No
Attending What School?
If yes, When?
Pediatric Patients Only
Labor and Delivery
Duration of Preganancy:
(Not length of labor)
Delivery: Vaginal C- Section
Birth weight:
Development
Age at sitting:
Age at walking:
Immunizations up-to-date?
Yes
No
1

Family Medical History Instructions: Please check the box of positive family medical history. Key: Paternal = Fathers Side. Maternal = Mothers Side
Relationship
Mother----------
Arthritis
Asthmas
Birth Defects
Cancer
Depression
Diabetes
Early Death
Heart Disease
High Boold Pressure
High Cholesterol
Kidney Disease
Learning disability
Mental Illness
Other
Stroke
Substance Abuse
Vision Loss
Father----------
Sister-----------
Brother---------
Maternal Aunt
Maternal Uncle
Paternal Aunt
Paternal Uncle
Maternal GM
Maternal GF
Paternal GM
Paternal GF
Other
Social History
Patient lives with:
Is the patient adopted?
Yes
No
Brothers: Sisters: Grade in school:
Tobacco Use
Former Use-------------- Yes No Packs/day Quit Date # of Years
Smokeless tobacco---
Yes
No
Quit Date
Comments
Alcohol Use-------------
Yes
No
Drinks/Week
Glasses of Wine
Cans of Beer
Shots of liquor
Drinks containing 0.5 oz of alcohol
Comments
Drug Use-----------------
Yes
No
Per Week
Types
Marijuana
Cocaine
Methamphetamines
IV
2

Current Problem
Reason for Today’s Visit:
Is visit due to Injury or Accident?
Yes
No
Injury Date:
Surgery Date:
How did it happen?
What treatment or tests
have you had for this
current problem?
Surgery
Splint/Brace
Injection
CT Scan
Xrays
EMG
Physical Therapy Massage Therapy :
Occupational Therapy Chiropractic Treatment :
MRI
Other Diagnostic Tests :
# of visits:
# of visits:
Types:
What activities make your pain worse?
What activities make your pain better?
How far can you walk?
When are your problems
most severe?
Morning
Afternoon
Evening
What is your normal
sleeping position?
Stomach Side lying Back
Have you had this problem before:
Yes No If Yes, Then when:
What stops you?
Consistent all day
Previous treatment?
Exercise prior to this problem: Regularly?
Yes
Yes
No
No
Are your complaints affecting your ability to exercise or generally
be active?
Additional questions: Do you frequently feel pain in your chest or
heart ?
Do you know of any other reason why you
should not do physical activity ?
Pain Rating: On a scale of zero to ten
0 (zero) being no pain ------ 10 (ten) being the worst pain imaginable
How would you rate the intensity of your pain?
If Yes, Then what:
What/How Often?
Yes
Yes
Yes
No
No
No
Your current pain:
Upper
x ^
+ =
x ^
+ =
x ^
+ =
Indicate on the diagram below the location of your current pain.
Do not indicate areas of pain which are not related to your
present problem: Upper
x
+
x
+
x
+
^
=
^
=
^
=
x
+
x
+
x
+
^
=
^
=
^
=
Now
Worst Day
Best Day
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
How stressful is the pain you are feeling?
5 6 7 8 9 10
5 6 7 8 9 10
5 6 7 8 9 10
Lower
x
+
x
^
=
^
Lower
x
+
x
^
=
^
Now
0
1 2
3 4
5 6 7 8 9 10
+
=
+
=
Worst Day
Best Day
0
0
1 2
1 2
3 4
3 4
5 6 7 8 9 10
5 6 7 8 9 10
x
+
^
=
x
+
^
=
Since this problem
began is the problem :
Your goals for treatment are:
Increasing Decreasing Unchanged
Pain location: (indicate on diagram)
x Dull/aching pain ^ Sharp pain
+ Pins and Needles = Numbness
3

CURRENT MEDICATIONS: PRESCRIPTION/NON-PRESCRIPTION
NAME OF MEDICATION
STRENGTH/DOSE
HOW DO YOU TAKE IT?
ALLERGIES (MEDICATIONS, FOOD, SEASONAL,
ETC)
NAME OF MEDICATION
DESCRIBE ADVERSE REACTION
4

Please indicate if you are currently experiencing any of the following conditions:
Review of Systems
Constitutional Yes No Yes No Yes No
Fever------------------------------------ Blurred Vision----------------------- Heartburn---------------------------
Chills--------------------------------------
Double Vision-----------------------
Nausea-------------------------------
Weight Loss-----------------------------
Sensitive to Light-------------------
Vomiting----------------------------
Fatigue-----------------------------------
Eye Pain----------------------------
Stomach Pain----------------------
Profuse Sweating----------------------
Eye Discharge----------------------
Diarrhea------------------------------
Weakness--------------------------------
Eye Redness-----------------------
Constipation--------------------------
Blood in Stool-----------------------
Dark Tarry Stools---------------------
Skin Yes No Cardiovascular
Yes No Genitourinary
Yes No
Rash------------------------------------ Chest pain------------------------- Painful Urination---------------------
Itching--------------------------------------
Pounding Heart-------------------
Urgency------------------------------
Shortness of breath relieved by
sitting up------------------------------
Frequency---------------------------
Blood in Urine------------------------
Side Pain-----------------------------
Leg Swelling----------------------
Head,Ears,Nose, & Throat Yes No Shortness of breath during
Headaches--------------------------------
Sleep / Rest---------------------------
---- Hearing Loss----------------------------
Ring in ears-------------------------------
Ear Pain------------------------------------
Respiratory
Yes No
Musculoskeletal
Yes No
Ear Discharge----------------------------
Nose Bleeds-------------------------------
Congestion--------------------------------
Wheezing---------------------------------
Sore Throat-------------------------------
Eyes Gastrointestinal Endo/Heme/Allergies
Cough--------------------------------
Coughing up Blood------------------
Phlegm Production------------------
Shortness of Breath------------------
Wheezing--------------------------
Muscle Pain-------------------------
Neck Pain---------------------------
Back Pain----------------------------
Joint Pain----------------------------
Falls------------------------------------
Easy Bruise/bleed--------------------
Environmental Allergies------------
Polydipsia (Excessive thirst)--------
Neurological
Dizziness----------------------------
Tingling-------------------------------
Tremors--------------------------------
Change in Sense of Touch--------
Speech Change----------------------
Hand, Arm, or Leg Weakness
Seizures------------------------------
Loss of Consciousness----------
Psychiatric
Depression--------------------------
Suicidal Ideas-----------------------
Substance Abuse---------------------
Hallucinations-------------------------
Nervous/Anxious---------------------
Sleeping Disorder-------------------
Memory Loss--------------------------
Yes
Yes
Yes
No
No
No
Any Other Symptoms:
SINCE YOUR LAST VISIT:
Have you had any changes to your health?
Yes
No
If Yes, Please Explain :
Have you been diagnosed with any conditions or diseases?
Have you had any surgical or invasive procedures?
Yes
Yes
No
No
If Yes, Please Explain :
If Yes, Please Explain :
Patient Signature:
Date:
5

NOTICE TO PATIENTS REGARDING DJ ORTHOPEDICS, LLC AND OTHER
PROVIDERS OF MEDICAL DEVICES & EQUIPMENT
To patients receiving treatment at the UF Orthopaedics & Sports Medicine Institute:
During the course of your treatment, your physician may prescribe certain medical
devices or equipment to help in treating your orthopedic condition. As a convenience to
patients at the UF Orthopaedics & Sports Medicine Institute, medical devices and
equipment are available on-site through DJ Orthopedics, LLC, an independent company. If
your physician recommends that you begin using medical device/s or equipment
immediately, you can obtain the equipment from DJ Orthopedics, LLC before you leave.
In other cases, you may decide to fill your prescription elsewhere. The following is a list
of local businesses that may be able to fill prescriptions for medical equipment. You may
find additional companies on-line.
Business Name
CVS Pharmacy
Walgreen Drug Stores
Mid Florida Prosthetics &
Orthotics
Address
Multiple
Multiple
6608 NW 9 Blvd, Gainesville
352-331-3399