Patient Name: ________________________________________________________
NEW PATIENT MEDICAL HISTORY FORM -07/2010
Are you Right handed Left Handed both/ambidextrous
Your family doctor is ___________________their office is in the city and state of ______________ What caused your pain? CAR ACCIDENT WORKERS COMP OTHER _______________ Please draw on the figure where the pain is/where it travels/radiates to R L L R
(example, back going down right leg to the foot)
The pain came on suddenly gradually when? ___________________
suddenly gradually when? ________________
If more than one location, what percentage of your pain is where?
(example 90% back 10% legs) ________________________________
Describe your pain. Check all that apply and if there is a space provided, say where on your body:
Electric shocks _________ Tingling _____________ Cramping Throbbing Sore Pins / needles __________ Numb ______________
Shooting ______________ OTHER (describe):_____________________________________
From 0 to 10, what does your pain range from during the day? (0 = no pain, 10 = unbearable)______ What makes it worse? (Check all that apply)
OTHER (describe):______________________________________________________________
What makes it better? (Check all that apply)
OTHER (describe): ______________________________________________________________
Is your pain ALL THE TIME HAS FLARE UPS BOTH: if flare ups, when? __________
G.M.O. This page has been reviewed ____________Date_________
Patient Name: ________________________________________________________
NEW PATIENT MEDICAL HISTORY FORM -07/2010 LIST ALL MEDICINES (psychiatric, diabetes, pain, etc.) YOU ARE TAKING OVER THE COUNTER OR FROM OTHER (NOT-Greater Metropolitan Orthopaedics) DOCTORS: No changes since last seen in a Greater Metropolitan Orthopaedics office so don’t need to write See the list I brought with me Anticoagulant/Anti-platelet Medicine (Check all that apply): Warfarin (Coumadin) Clopidogrel (Plavix)
Aggrenox / Any other blood thinners______
Medication Medication Medication Medication
Do you have any ALLERGIES to the following medications or items?
------------------------------------------------------------------------------------------------------------------------- Are you satisfied on your current pain meds? _________ Do you have enough medication? ______
What PAIN MEDICATIONS have you tried and STOPPED taking?
Stopped because (side effect of, no relief, etc.)
G.M.O. This page has been reviewed ____________Date_________
Patient Name: ________________________________________________________
NEW PATIENT MEDICAL HISTORY FORM -07/2010
Have you had any of the following within the last MONTH? (REVIEW OF SYSTEMS)
Fever (General) Balance problems (Neuro)
shortness of breath (Resp)
edema /Leg swelling (Cardiac) drowsiness
abdominal / stomach pain (GI)
Constipation with bowel movement muscle weakness WHERE?:___________________
Itchy skin (Skin)
lost weight without eating less
depressive symptoms/Feelings of sadness (Psych)
sleep disturbance/insomnia/ Difficulty sleeping
libido decrease/low sex drive (GU) suicidal/ Thoughts of harming yourself (MUSCULOSKELETAL)
R L Hand tingling that wakes you up at night
R L Hand tingling that improves with shaking it
SOCIAL HISTORY
OCCUPATION: __________ disabled homemaker office work retired unemployed
NOT WORKING since ______________* STILL WORKING with…. *
Do you smoke? Yes No How many packs a day? ______________________ ALCOHOL don’t drink every day (minimal) 1-2 drinks a day (moderate) more than 3 drinks a day (heavy) less than a few times a year (seldom/rare) ANY previous illegal drug use: ____________________________________________________
G.M.O. This page has been reviewed ____________Date_________
Patient Name: ________________________________________________________
NEW PATIENT MEDICAL HISTORY FORM -07/2010 PRIOR PAIN PAST SURGICAL HISTORY PAST MEDICAL HISTORY TREATMENTS/ What surgeries have you had? What are your medical problems? FAMILY HISTORY
What have you tried No previous surgery No significant medical disease ORTHOPEDIC SURGERIES Alcoholism PHYSICAL ARTHROSCOPES… MODALITIES: INJECTION JOINT REPLACEMENTS. SPINE-please describe, like FAMILY HISTORY OTHER SURGERIES (yours) Does your family have breast augmentation Any of the problems Listed below? ANY OTHER SURGERIES?
Is there anything else we should know? ___________________________________________________
G.M.O. This page has been reviewed ____________Date_________
University of MN Medical Center, Fairview – I. Describe prescription drug interactions with common immunosuppressants, cholesterol-lowering agents, steroids, antivirals and Bactrim. medication interactions and which OTCs to avoid– III. Describe herbal medications that may be harmful and what interactions have been described in the literature. • Immunosuppressants • Steroids
Patient Name: ________________________________________________________
NEW PATIENT MEDICAL HISTORY FORM -07/2010