New Patient Questionnaire HIP Adult Reconstruction & Joint Replacement
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- Norah Warren
- 6 years ago
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1 New Patient Questionnaire HIP Adult Reconstruction & Joint Replacement Name: DOB: Date: Height: Weight: Age: Chief Complaint Laterality Left Right Both Please describe your symptoms: (Mark all that apply) Throbbing pain Radiating pain Dull pain Sharp pain Catching/Locking Swelling Stiffness Instability Other: Where is the pain located in your hip? (Mark all that apply) Groin Thigh Outside Buttocks Other: Current Pain Level (no pain 0 10 highest) While Walking While negotiating stairs At rest (sitting, lying down, sleeping) When did this condition start? How did start? What makes the pain better? What makes the pain worse? Have you EVER tried any prior conservative treatment? How long? Did it help? Acupuncture or holistic remedies Arthroscopic surgery Brace / Cane / Crutches / Walker Cortisone injections Dietary supplements Viscosupplementation (Gel injections) NSAIDS (eg: Ibuprofen, Aspirin, Naproxen, Celebrex, Voltaren) Narcotics Physical therapy Weight loss Exercise program Activity modification / Lifestyle change
2 Functional Assessment Do you have a limp? No Slight Moderate Severe What type of support do you use for walking? None Cane (long walks) Cane (full time) Crutch(es) Walker What distance are you able to walk? Unlimited 6 blocks 2-3 blocks < 1 block Bed to chair How do you climb stairs? Normally With banister With assistance of a person Unable To what extent are you able to put on shoes and socks? Easy Difficult Unable Describe the extent to which you are able to sit: Any chair, 1 hour High chair, 30 minutes Unable Are you able to use public transportation? Yes No Do you find this situation to be: Acceptable Unacceptable HOOS, JR. Hip Survey Instructions: This survey asks for you view about your hip. This information will help us keep track of how you feel about your hip and how well you are able to do your usual activities. Answer every question by ticking the appropriate box, only one box for each question. If you are unsure about how to answer a question, please give the best answer you can. Which Hip: Left Right Both Pain: What amount of hip pain have you experienced the last week during the following activities? Going up or down stairs: Walking on an uneven surface: Function, daily living: The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities, please indicate the degree of difficulty you have experience in the last week due to your hip. Rising from sitting: Bending to floor/pick up an object: Lying in bed (turning over, maintaining hip position): 6. Sitting:
3 Medications: Please list the medications that you CURRENTLY take Medication Route (oral, injection, etc.) Dose Frequency Allergies: Please include any known allergies Allergy Reaction Are you allergic to iodine? Are you allergic to latex? Are you to metal, jewelry, or nickel? Medical History Please select any past or current medical conditions below: Anxiety Depression Kidney disorder Pulmonary embolus Arrhythmia (Irregular heartbeat) Diabetes Low acting thyroid Reflux Asthma Heart attack Open wounds/ulcers Rheumatoid arthritis Bleeding problems Heart failure (CHF) Osteoarthritis Seizures Blood clots (DVT-PE) High blood pressure Osteoporosis Stomach ulcers Cancer Coronary artery disease High cholesterol Peripheral vascular disease Stroke Infection Pneumonia Other: Surgical and Hospitalization History Previous operation/hospitalization Occurrence date (approx.) Have you ever had a problem with anesthesia? Problem: Have you ever had complications from prior surgery? Problem:
4 Family History What medical problems run in your direct family? Family member Problem Alive/Deceased Father Mother Brother Sister Grandfather Grandmother Social History Are you a tobacco user? If yes, what? How much? Do you consume alcohol? If yes, what kind? Drinks per week? Recreational drug use? If yes, what drug? How much and how often? List any recreational activities / sports that you enjoy: What do you do for a living? With whom do you live? Screening Questions (Coordination of Care) Are you currently on any blood thinners? Have you ever had a MRSA Infection? Do you have any of the following medical devices? (Mark all that apply) Pain Pump Neurostimulator Pacemaker and/or Defibrillator Shunt for hydrocephalus Do you have diabetes? If yes, do you have an insulin pump? Have you been taking opioids for 6 months or more (e.g. codeine, percocet, morphine, Vicodin, etc.)? Immunizations and Falls Screening Have you received the pneumonia vaccine? If yes, date? If not, why? In the past year, did you received the Influenza (flu) vaccine between October 1st and March 31st? If yes, date? Have you fallen 2 or more times within the past year, or fallen with injury in the past year? If yes, do you have vision problems that may have contributed to your fall?
5 Review of Systems Are you currently having, or have you had any of these problems in the past year? (Select all that apply): Constitutional Hematologic Respiratory Skin Chills Easy bruising/bleeding Increased sputum Sores/ulcers Fever Blood clots in legs Cough Itching Sleep difficulty Blood clots in lungs Difficulty breathing Dryness Fatigue Wheezing Hives Night sweats Excessive snoring Rash Weight Change Mole changes ENT Cardiovascular Endocrine Musculoskeletal Double vision Chest pain Cold intolerance Joint pain Headaches Leg swelling Heat intolerance Arthritis Hearing loss Palpitations Excessive thirst Muscle pain Cataracts Poor circulation Excessive hunger Joint swelling Glaucoma Cold hands Muscle cramps Dry eyes Cold feet Muscle weakness Sinus problem Joint stiffness Gastrointestinal Genitourinary Neurological Psychiatric Abdominal pain Bladder incontinence Seizures Depression Trouble swallowing Blood in urine Dizziness Anxiety Heartburn Urinary difficulty Weakness Mood swings Nausea Painful urination Loss of balance Memory problems Vomiting Urinary retention Numbness Nervousness Constipation Urinary urgency Paralysis Insomnia Eyes Environmental Allergies Mouth Dryness Pollen Bad breath Discharge Dust Mites Bleeding gums Double Vision Pets/Animals Sores ulcers Pain Mold/Mildew Dental problem Redness Metal Loss of taste None None None
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Name: DOB: Date: Front Back Inside Outside Other: While Walking While negotiating stairs
NEW NEE EN Name: DOB: Date: Height: Weight: Age: Chief Complaint Laterality Left Right Both Please describe your symptoms: (Mark all that apply) Throbbing pain Radiating pain Dull pain Sharp pain Catching/Locking
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A. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking.
New Patient Questionnaire Please complete this and bring it with you to your visit. If you have it completed five days or more prior to your visit, please mail or fax it to our office. Most recent treating
Integrative Consult Patient Background Form
Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
* CC* PATIENT QUESTIONNAIRE
Pain Center of Michigan *0290341CC* PATIENT QUESTIONNAIRE Patient Name Birthdate Age Home Address City State Zip Home Phone Alternate Phone Referring Physician Primary Care Physician MEDICAL HISTORY Please
Pharmacy Name/Location/Phone number:
Pharmacy Name/Location/Phone number: Family Physician Name: Phone: Address: Referring Physician Name: Phone: Address: First Emergency Contact: Relationship: Home/cell phone: Work phone: Second Emergency
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address: