Patient Name Date MR#: FLORIDA ORTHOPAEDIC INSTITUTE. Race: Ethnicity: (Circle one) Hispanic / Not Hispanic
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1 FLORIDA ORTHOPAEDIC INSTITUTE LOWER EXTREMITY PATIENT QUESTIONNAIRE Patient Name: Family/Primary Doctor: Phone: Family/Primary Doctor s Address: Who referred you to Florida Orthopaedic Institute? (Name & address please): INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Circle the word or phrase that best describes your situation. You may select more than one answer per question. Answer in as much detail as possible. Write additional information in the margins. The information you provide will help your doctor to more accurately understand your problem(s) and develop an appropriate plan of treatment for your care. THANK YOU. Sex: Height: Date of Birth: Weight: Age: Race: Ethnicity: (Circle one) Hispanic / Not Hispanic Language: Occupation: What is your current smoking/tobacco usage status? Current tobacco non-user Current tobacco smoker Current smokeless tobacco user (eg. Chew, snuff) Have you ever received a Pneumonia vaccination? Pneumonia vaccination administered or previously received Pneumonia vaccination NOT administered or previously received for medical reasons Pneumonia vaccination NOT administered or previously received, reason not specified CHIEF COMPLAINT Which problem/symptoms are you seeing the doctor for today? Low Back Right Hip Left Hip Right Knee Left Knee
2 If more than one problem/symptom, which is the worst? Low Back Right Hip Left Hip Right Knee Left Knee What is the date the problem began? (Approximate if unsure): Month: Day: Year: Is your problem the result of an injury? Yes No Is your problem the result of a work injury? Yes No Have you seen a physician in the past for this problem/injury? Yes If yes, who & when: No What caused your injury? Fall Lifting Throwing Reaching Pulling Fighting Twisting Collision/Contact Other: Have you received previous treatment for your current problem? Yes No
3 If yes, specify treatment type: (check all that apply) NSAIDS: Pain Medications: Formal Physical Therapy: Injections: # of injections Brace/Cane: Other: Do any of the following improve or worsen the problem? Climbing stairs Improves Worsens No change Descending stairs Improves Worsens No change Walking Improves Worsens No change Resting the area Improves Worsens No change Sleeping Improves Worsens No change Medication Improves Worsens No change Medication: Check the words that best describe the character of the pain you are having today: Aching Burning Exhausting Gnawing Miserable Nagging Numb Penetrating Sharp Shooting Stabbing Tender Throbbing Tiring Unbearable
4 On a scale of 0 10 (with 10 being the worst pain imaginable) how would you describe your pain? What brings on this problem? (When does this problem occur?) After exercise After work While at work With activity Suddenly Over a period of time Other: Have you had any other symptoms with this problem? Locking Tenderness/pain Swelling Fevers Chills Weakness Stiffness Instability
5 PAST MEDICAL HISTORY Do you have any of the following medical problems? have no known medical problems Adult onset diabetes Afib Anxiety Asthma Auto Immune Disorder Blood clot (DVT) Cancer CHF COPD/Lung problems Coronary artery disease Depression Emphysema Heart disease Hepatitis (type: ) High blood pressure High cholesterol Liver disorder/cirrhosis Osteomyelitis Osteoporosis Overweight Peripheral vascular disease Rheumatoid Arthritis Seizure disorder Thyroid disease Ulcer disease Other:
6 SURGICAL HISTORY Have you ever had any of the following hip/knee surgeries? Arthroscopy: Hip (Previous Surgery Year: Location (R/L): ) Knee (Previous Surgery Year: Location (R/L): ) Joint Reconstruction (Arthroplasty): Shoulder (Reason: Previous Surgery Year: Location (R/L): ) Elbow/Wrist (Reason: Previous Surgery Year: Location (R/L): ) Hip (Reason: Previous Surgery Year: Location (R/L): ) Knee (Reason: Previous Surgery Year: Location (R/L): ) Ankle (Reason: Previous Surgery Year: Location (R/L): ) Joint Replacement: Shoulder (Reason: Previous Surgery Year: Location (R/L): ) Elbow/Wrist (Reason: Previous Surgery Year: Location (R/L): ) Hip (Reason: Previous Surgery Year: Location (R/L): ) Knee (Reason: Previous Surgery Year: Location (R/L): ) Ankle (Reason: Previous Surgery Year: Location (R/L): ) Fracture Repair: Shoulder (Reason: Previous Surgery Year: Location (R/L): ) Elbow/Wrist (Reason: Previous Surgery Year: Location (R/L): ) Hip (Reason: Previous Surgery Year: Location (R/L): ) Knee (Reason: Previous Surgery Year: Location (R/L): ) Ankle (Reason: Previous Surgery Year: Location (R/L): ) Have you ever had any of the following spine surgeries? Fusion - Cervical Spine (Reason: Previous Surgery Year: ) Fusion - Lumbar Spine (Reason: Previous Surgery Year: ) Discetomy - Cervical Spine (Reason: Previous Surgery Year: ) Discetomy - Lumbar Spine: (Reason: Previous Surgery Year: ) Laminectomy (Reason: Previous Surgery Year: )
7 Other Surgeries Appendectomy (Year: ) CABG (Year: ) Cardiac Stents (Year: ) Cholecystectomy (Year: ) Hysterectomy (Year: ) Herniorrhaphy (Year: ) Mastectomy (Year: ) Splenectomy (Year: ) Pacemaker (Year: ) Prostectomy (Year: ) Other: (Year: )
8 SOCIAL HISTORY What is your current alcohol usage? Currently drink alcohol Used to drink but stopped Never used alcohol If you drink alcohol, how frequently to you consume it? Rarely drink (<1per month) Drink alcohol occasionally (1-4 per month) Drink alcohol socially (1-2 per week) Drink alcohol frequently (3-5 per week) Drink alcohol daily What is your current tobacco usage? Currently use tobacco Do not currently use tobacco, but used to Never used tobacco If you use or used to use tobacco, how many cigarette packs per day? ½ Pack 1 Pack 1 ½ Packs 2 Packs 2 ½ Packs 3 Packs 3 ½ Packs 4 Packs How many years have you used tobaccos? Do you now or have you ever used drugs? No, I do not use drugs Cocaine Marijuana Recreational Other:
9 FAMILY HISTORY Has anyone in your immediate family ever had any of the following? (Mark all that apply) Please specify whether history is for mother, father, sister, brother, grandmother or grandfather. None known Alcoholism (Affected Family Member: ) Anxiety/depression (Affected Family Member: ) Asthma (Affected Family Member: ) Bleeding/clotting problems (Affected Family Member: ) Cancer (Affected Family Member: ) Colitis (Affected Family Member: ) Coronary artery disease (Affected Family Member: ) Diabetes (Affected Family Member: ) Heart disease (Affected Family Member: ) High cholesterol (Affected Family Member: ) Hypertension (Affected Family Member: ) Hypothyroidism (Affected Family Member: ) Leukemia (Affected Family Member: ) Osteoarthritis (wear & tear) (Affected Family Member: ) Rheumatoid arthritis (Affected Family Member: ) Rheumatic fever (Affected Family Member: ) Scoliosis (Affected Family Member: ) Seizure disorder (Affected Family Member: ) Stroke (Affected Family Member: ) Tuberculosis (Affected Family Member: ) Other: (Affected Family Member: )
10 REVIEW OF SYSTEMS Have you recently experienced any of the following? Please circle YES or NO. Comments GENERAL - Weight gain YES NO - Weight loss YES NO - Night sweats YES NO EYES - Loss of vision YES NO - Double vision YES NO EAR/NOSE/THROAT - Hearing loss YES NO - Nose bleeds YES NO GASTRO INTESTINAL - Nausea YES NO - Vomiting YES NO - Change in bowel habits YES NO - Heartburn YES NO RESPIRATORY - Shortness of breath YES NO - Coughing/wheezing YES NO HEART - Chest pain YES NO - Palpitations YES NO - Fainting YES NO UROLOGY - Frequent urination YES NO - Difficulty with urination YES NO - Blood in urine YES NO VASCULAR - Swelling in lower extremities YES NO - Emboli (blood clots) YES NO MUSCULOSKELETAL - Muscle weakness YES NO - Stiffness YES NO - Joint pain YES NO PSYCHIATRIC - Anxiety YES NO - Depression YES NO - Confusion YES NO - Memory loss YES NO
11 MEDICATIONS AND ALLERGIES Are you currently taking any medications? Yes No Patient Current Medications: Medication Name Dose For what purpose? Do you have any allergies? Yes No Please list all allergies (including iodine and contract dyes): Allergy: Severity: 1 Mild Moderate Severe 2 Mild Moderate Severe 3 Mild Moderate Severe 4 Mild Moderate Severe 5 Mild Moderate Severe 6 Mild Moderate Severe 7 Mild Moderate Severe
12 Pharmacy Name PREFRERRED PHARMACY INFORMATION Pharmacy Street Address City, State, Zip If address unknown please provide crossroads Pharmacy Phone Number Everything I have answered is true and correct to the best of my knowledge. Patient Signature: Date:
I.Ill"' FLORIDA '"I ORTHOPAEDIC INS'I'I1'U'I'E" HEALTH A U'iF Hea lth Acadenuc Affilime. Keeping you active. Dear Patient,
FELLOWSHIP TRAINE SURGICAL SU BSPECIALISTS Foot & Ankle Hand & Wrist Interventional Spine Joint Replacement Oncology Shoulder & Elbow Spine Surgery Sports Medicine Trauma & Fracture NON-SURGICAL SERVICES
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INSTITUTE FLORIDA ORTHOPAEDIC. 9% Stem 1m, 776D. Keeping you active. offer my expertise and counseling to our other patients in need.
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