ORTHOPEDIC HISTORY Name: _________________________________________ Today’s Date: ________________ Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs Primary Doctor Name and Address: Referring Doctor Name and Address: ______________________________________ ______________________________________ ______________________________________ ______________________________________ If not referred, how did you choose this office? ____________________________________________ Why are you seeing the doctor today? (body part) __________________________________________ How long has the pain/problem been present? _____________________________________________ Has the pain/problem worsened recently? No Yes, how recently?________________________ What started the pain/problem? ________________________________________________________ Quality of the pain: Sharp Burning Dull Aching How severe is the pain at the location described above? No Pain Mild Moderate Severe What makes the pain/problem better? ___________________________________________________ What makes the pain/problem worse? ___________________________________________________ Is the pain (check all that apply): Continuous Activity Related Night Pain Unpredictable Did this problem start at work? ________________________________________________________ Have you already filed or will you file a Workers’ Compensation claim? _______________________ Have you missed work because of this problem? __________________________________________ What ever treatments have you tried? Physical Therapy/Exercise TENS unit Narcotic medications Cass/boot Massage/Ultrasound Traction Anti-Inflammatories Orthotics Manipulation Surgery Steroid injections Braces Are you right hand ___ or left ___? Previous physicians seen for this problem Physician Specialty City Treatment
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ORTHOPEDIC HISTORY Name: _________________________________________ Today’s Date: ________________
Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs
Primary Doctor Name and Address: Referring Doctor Name and Address:
Currently controlled with insulin oral medications diet Other: __________________________________________________________________________
__________________________________________________________________________________ PAST SURGICAL HISTORY: No Prior Surgery
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Have you every had general anesthesia? No Yes If yes, have you had any problems related to this? No Yes Please explain any problems related to general anesthesia: ___________________________________ __________________________________________________________________________________
Alton Orthopedic Clinic
John Stirnaman MD - Board Certified Orthopedic Surgeon
Michael Taylor MD - Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD - Rheumatologist
Donald LeMoine PA-C
#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002
COMPREHENSIVE HEALTH HISTORY MEDICATIONS (prescribed and over the counter): I take no medications
METAL ALLERGIES: No Allergies YES_______________________________(List Metals)
SOCIAL HISTORY:
Work status
Working Homemaker Unemployed Disables On Leave Retired Student
Do you live alone? ______ If no, who lives with you? ______________________________________
Are you currently smoking?_____ If yes, how many packs a day?___ For how many years?_______
How many packs a day did you previously smoke? ___ Other forms of tobacco? ________________
Alcohol Use Never Rare Social Frequently (more than twice a week) Alcoholic Recovering Alcoholic Illegal Drug Use Never In the past Currently Types of Drugs_____________________
Name of Medication Dose Reason
ALLERGIES TO MEDICATIONS: No Allergies
Name of Medication Reaction (rash, swelling, stomach upset, etc.)
Alton Orthopedic Clinic
John Stirnaman MD - Board Certified Orthopedic Surgeon
Michael Taylor MD - Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD - Rheumatologist
Donald LeMoine PA-C
#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002
COMPREHENSIVE HEALTH HISTORY FAMILY HISTORY: Check all that apply None Apply
FOR OFFICE USE ONLY I have read and confirmed the above information with the patient/family: Physician Signature:_______________________________________ Date:_______________________