Is this a referral? Who?____________. If not: how did you hear about us?_________________
Symptoms
What hurts?_________________Left or Right side?
When did your symptoms begin? __________________ (months or weeks ago)
Did they start spontaneously or did you have an injury? If an injury please describe:__________________________________________________________________________
What are your symptoms now? Pain, instability, difficulty sleeping
Pain on a scale of 1-10: ______. How would you describe your pain? Dull, sharp, intermittent, constant.
What previous therapies have you tried? Physical therapy, anti-inflammatory medicine (Ibuprofen etc), surgery, activity modification, steroid injections, alternative therapies (acupuncture, prolotherapy, etc), other: __________________________________
What does the pain keep you from doing that you want to do?__________________________________
If surgery: what type, when, and who was the surgeon?_______________________________________
Review of Symptoms
Any unexplained weight loss, fever or chills?______
Any allergies to Metal or artificial nails? ______
Past Medical History
Do you have: heart problems (heart attack, CHF, clogged heart vessels), high blood pressure, high cholesterol, diabetes, blood flow problems to your extremities, thyroid problems, history of blood clots, bleeding problems, psychiatric illness, chronic pain syndromes, rheumatologic problems, cancer?
Other? ________________________________________________________________________
Past Surgical History
What non-orthopedic surgeries have you had? _______________________________________________________________________
Did you have any complications?_____________________________________________
Family History
Do you have a family history of anesthesia problems, blood clots, or bleeding problems? Yes or No.
Social History
What sports do you enjoy?_______________________________________
Are you a non-athlete, recreational, competitive or collegiate/professional athlete?
What is your profession? ___________________________________
Smoke ? y./n
Drink a lot? y/n
Today
What can we do to make this appointment a success? __________________________