Patient History. Name: M.D. Sent Report Yesڤ Noڤ M.D. Sent Report Yesڤ Noڤ

Transcription

1 Name: Date: Patient History Please answer the following questions to the best of your ability. The nurse and doctor will review this information with you. We appreciate your cooperation. Thank you. Referral Information What physician sent you to this treatment center? Name: M.D. Sent Report Yes No M.D. Sent Report Yes No Is there any other physician you wish to send a report to other than the above? If yes, write name and address below: Name: Address: How did you find out about this treatment center? Nurse Physician Newspaper/Magazine Radio TV Other Friend/Relative Other Health Professional Have you ever been a patient in this practice before? Yes No Psychological/Social Lives: Alone With Relationship Person to notify in an emergency: Relationship Telephone:

2 Pertinent family information: Alcohol Use Drug Use Aware of Prevention of Sexually Transmitted Diseases? Concerns related to present illness: Work/Leisure Activities/Hobbies: Any history of mental illness/depression: Yes No If yes, please explain: Financial Concerns: Yes No Tobacco Use: Past Yes No Date stopped: Present Yes No Type: Wound History 1. Reason for coming to the treatment center. 2. Location of wound. (be specific) 3. How did the wound start? Injury/Accident Surgical Incision or Procedure Burn Appeared Gradually Over Time Other Explain 4. When did your wound start? Month Year 5. Has it ever completely healed? Yes No

3 6. Have you ever been treated for your wound? Yes No If yes, check the following treatments that have been used on your wound(s): Plain Gauze Dressing Yes No Transparent Dressing Yes No Foam Dressing Yes No Hydrocolloid Dressing Yes No Topical Gel/Ointment Yes No Alginate Dressing (seaweed) Yes No Unna Boot Yes No Total Contact Cast Yes No Topical Antibiotic Yes No Whirlpool Yes No Soaks Yes No Hyperbaric Oxygen Yes No Compression Stockings Yes No Type: 7. Have any doctors ever discussed the possibility of amputation of this leg or foot with you? No Yes If yes, please explain. 8. Have you had any of the following tests related to this wound? Date Date Arteriogram Yes No Bone Scan Yes No Angioplasty Yes No X-Ray Yes No Arterial Doppler Yes No CT Scan Yes No Venous Doppler Yes No Other: Health History 1. Do you have allergies? Food Yes No Describe: Penicillin/Sulfa Yes No Describe: Iodine Yes No Describe: Aspirin Yes No Describe: Novocain Yes No Describe:

4 Codeine Yes No Describe: Adhesive Tape Yes No Describe: Dyes Yes No Describe: Other: 2. List all medications you now take: Medication Dose/Amount Frequency Purpose 3. Check all health problems/diseases you have had: (If yes, fill in month/year and description) Month & Year Description Back or Neck Injury Yes No Thyroid Problems Yes No Diabetes Mellitus Yes No Breathing/Lung Problems Yes No Stroke or Seizures Yes No Heart Attack Yes No Kidney Problems Yes No Eye Problems Yes No Rheumatoid Arthritis Yes No Cancer Yes No High Blood Pressure Yes No Gastric (stomach) Yes No Constipation/Diarrhea Yes No Blood Clots Yes No Leakage of Urine/Stool Yes No Nerve Problem Yes No Muscle Problem Yes No Recent exposure to infectious disease? TB Yes No Hepatitis Yes No Aids Yes No Previous blood transfusion Yes No

5 Have you ever received anesthesia? Local Yes No Reaction? Yes No General Yes No Reaction? Yes No Spinal Yes No Reaction? Yes No Nerve Block Yes No Reaction? Yes No 4. If you have diabetes, please fill in the blanks and circle the appropriate choices for the questions below regarding glucose monitoring. I monitor my glucose regularly Yes No If yes, please answer the following: I test my urine times a day / week with: Clinitest Diastix Chemstrip UG Testape Other: I test my blood times a day / week with: Chemstrip Visidex Accu-chek Glucometer II Glucoscan II Other: My glucose usually runs: Morning Noon Dinner Bedtime Who treats your diabetes? Physician s name: 5. List all the surgeries you have had: Type of Surgery Month & Year Description Hip or Leg Surgery Yes No Eye Surgery Yes No Heart Surgery Yes No Kidney Transplant Yes No Amputation Yes No Skin Grafts Yes No Blood Vessel Surgery Yes No Ostomy (type) Yes No Other Yes

6 6. Nutrition Chewing/swallowing problems? Yes No Problems with dentures? Yes No Loss of appetite? Yes No Weight loss greater than 5 lbs in the past month? Yes No Weight gain greater than 5 lbs in the past month? Yes No Follow diet restrictions at home? Yes No Type of diet: Patient s Signature: Date: Nurse s Signature: Date: