NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE

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1 NEW PATIENT DEMOGRAPHICS QUESTIONNAIRE Today s : Patient Name: DOB: Race White/Caucasian Black/African American Asian Native American Alaskan Native Native Hawaiian Pacific Islander Other: Preferred Language: English Spanish Sign Language Other: Ethnicity: Hispanic Yes No Migrant and Seasonal Employment: Have you or someone in your household ever been employed in agriculture/farming? Yes No In the past two years, have you or someone in your household moved to another area (established a temporary home) in order to work in agriculture? Yes No In the past two years, have you or someone in your household worked in agriculture without the need to move away from your home? Yes No Have you or someone in your household stopped traveling to work in agriculture because of retirement or a disability? Yes No Marital Status: Single Married Divorced Widowed Domestic Partnership Patient Signature New Patient Demographics Questionnaire English (Ortho) 03/24/2014

2 NEW PATIENT INTAKE FORM Today s : Patient Name: DOB: Primary Care Physician: Who referred you to this office? Name: Relationship: CURRENT INJURY OR PROBLEM Reason for today s visit: Left Right Was this injury a result of: Auto accident Work Injury Name of employer: School/Sports Injury Name of school/team: Other When did your injury occur / problem begin? Briefly describe how your injury/problem occurred: Have you been seen by a specialist in the past for this condition? Yes No If yes, name of the specialist(s): (s) of treatment: Which treatments have you received for this condition: PAIN EVALUATION What is the quality of your pain (check all that apply)? Sharp Dull Stabbing Aching Throbbing Burning What is the severity of your pain most of the time? (0 being no pain, 10 being the most imaginable pain) Is the pain (check all that apply): Constant Intermittent Worse in the morning Worse at end of day Worse at night

3 What other symptoms do you experience with this condition? Bruising Swelling Locking Popping Instability Limp Stiffness Numbness Tingling Other What activities make your symptoms worse? Standing Walking Stairs Squatting Kneeling Twisting Bending Sitting Exercise Lifting Overhead activities Coughing/sneezing What makes your symptoms better / improves your pain? Ice Heat Massage Rest Ibuprofen Narcotics Elevation Bracing What other symptoms are you experiencing today (check all that apply): Fever Chills Night sweats Headache Vision loss Double vision Anxiety Depression Heartburn Ulcers Cough Shortness of breath Chest Pain Irregular heart beat Constipation Diarrhea Bleeding Bruising Environmental allergies Rash Gout Dizziness Seizures Painful urination Blood in urine Rheumatoid arthritis Other SURGICAL HISTORY - List any previous surgeries and approximate dates Surgery of Surgery MEDICATION HISTORY - List all medications you are presently taking Medication Dosage Frequency

4 ALLERGIES - List any confirmed latex, drug, or food allergies and your reaction to them Allergy Reaction FAMILY HISTORY Identify family history of illness: Mother Father Sister Brother Family History of: Age of onset Died from this cause? Yes No Age at death Mother Father Sister Brother Family History of: Age of onset Died from this cause? Yes No Age at death Mother Father Sister Brother Family History of: Age of onset Died from this cause? Yes No Age at death SOCIAL HISTORY Who is your employer? Occupation? What are your hobbies? What is your current smoking status? Current Previous Never What type of tobacco use: Cigarettes Cigars Smokeless/Chew Pipe How many/day (packs-if cigarettes): If you quit, when did you quit? Do you drink alcohol? Yes No If yes, drinks per week: Type(s) of Alcohol: Do you exercise? Yes No If yes, how often: 1-3 times a week 3-5 times a week Daily Patient Signature Guardian Signature

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