Hand Team Intake Form
Hand Team Intake Form
Hand Team Intake Form
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<strong>Hand</strong> & Upper Extremity Center – Orthopaedic Surgery<br />
Roger A. Daley, MD PhD Steven I. Grindel, MD<br />
PATIENT INFORMATION<br />
(PLEASE PRINT)<br />
Today’s Date<br />
Name Age Sex M F DOB<br />
Referred By<br />
Which hand do you write with? Right Left Both<br />
CHIEF COMPLAINT<br />
Reason for today’s visit<br />
Injured/Painful Side Right Left Both<br />
What type of problem/injury is this? Auto Accident Work Related Injury Other<br />
Onset of symptoms: Sudden (date of injury) / / Gradual (for how long)<br />
How did your symptoms begin or how did your injury occur?<br />
Check which best describes your current symptoms/complaints (check all that apply) Intermittent (on & off) Constant<br />
Pain Swelling Bruising Numbness Stiffness<br />
Giving out Tingling Popping Weakness Locking<br />
Other<br />
What makes symptoms better?<br />
worse?<br />
What is your pain level (please circle) 0 1 2 3 4 5 6 7 8 9 10<br />
No Pain Moderate Severe<br />
Have you ever had similar symptoms in the past? Yes No When<br />
Have you seen another doctor for this problem? Yes No Doctor (Name)<br />
What treatments have you had<br />
PAST MEDICAL HISTORY<br />
Have you been diagnosed with any of the following Medical Conditions? (Check all that apply)<br />
Asthma Heart Disease Thyroid Disease Stomach / Bowel<br />
COPD High Blood Pressure Neurological Disease Cancer<br />
Rheumatologic Disease High Cholesterol Stroke / TIA Kidney Disease<br />
Osteoarthritis Diabetes Liver Disease History of Substance Abuse<br />
Gout Bleeding Tendencies / Blood Clots Hepatitis Anxiety / Depression<br />
Osteoporosis Sleep Apnea Varicose Veins Other<br />
PAST SURGICAL / HOSPITALIZATION HISTORY<br />
Reason<br />
Date
MEDICATIONS (Include prescription, over‐the‐counter, vitamins and herbals)<br />
Reason Taking Medication<br />
Dosage (How many per day)<br />
ALLERGIES (Medications, Dyes, Latex, Adhesive Tape, Anesthesia, Environmental)<br />
(List)<br />
None<br />
SOCIAL HISTORY<br />
Marital Status Single Married Divorced Separated Widow(er)<br />
Employment Employed Unemployed Student Retired Minor<br />
Occupation / Brief description<br />
Are you currently working?<br />
Yes, regular duty<br />
Yes, restricted duty (explain)<br />
No, last day of work?<br />
List activities/hobbies you participate in<br />
Current use of alcohol No Yes # of drinks per week<br />
Current use of tobacco No Quit (date) Yes # of years ______ packs/day ______ Type: Cigarettes/Pipe Smokeless<br />
Current use of recreational drugs No Type / Date Last Used<br />
Current use of caffeine Coffee per day Soda per day<br />
FAMILY HISTORY<br />
Asthma Heart Disease Thyroid Disease Stomach / Bowel<br />
COPD High Blood Pressure Neurological Disease Cancer<br />
Rheumatologic Disease High Cholesterol Stroke / TIA Kidney Disease<br />
Osteoarthritis Diabetes Liver Disease History of Substance Abuse<br />
Gout Bleeding Tendencies / Blood Clots Hepatitis Anxiety / Depression<br />
Other<br />
HEALTH REVIEW (Please check if you are CURRENTLY experiencing any of the following)<br />
Changes in weight Fever Night Sweats Swollen lymph nodes Fatigue HIV/AIDS<br />
Easy bleeding/bruising Headaches Dizzy Spells Concussions/Head trauma Rashes Fainting<br />
Visual Changes Chest Pains Palpitations Incoordination/Imbalance Cough Hepatitis<br />
Circulatory problems Ears Ringing Painful urination Bloody/black stools Diarrhea Constipation<br />
Abdominal pain Nausea Ulcers (stomach) Shortness of breath Vomiting Blood in urine<br />
Frequent urination Post‐menopausal Other<br />
Is your primary doctor aware of these complaints? Yes No<br />
Patient Signature<br />
Date<br />
Physician Review<br />
Date
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