The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION
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1 The Orthopedic Center of St. Louis John O. Krause, M.D. Orthopedic Surgery; Surgery of the Foot & Ankle NEW PATIENT INFORMATION Name: Daytime Phone Number: Date of Birth: / / Age: How did you hear about Dr. Krause? Referring Doctor: Primary Care Physician: Address: Phone # Chief Complaint: Date of Accident/Onset: / / Which side is your problem on? Right Left Please describe the recent events that brought on this orthopaedic problem: How long has it been a problem? How often do you have pain? What makes it worse? What makes it better? Have you had prior treatment for this injury? Yes No When? ByWhom? What Treatment? Neck Shoulder area Elbow Forearm Wrist Hand Hip Thigh Knee area Calf area Ankle Foot Neck Shoulder area Elbow Forearm Wrist Hand Hip Thigh Knee area Calf area Ankle Foot
2 HEALTH HISTORY Height Weight Shoe Size Do you have diabetes? Yes No Do you have fibromyalgia? Yes No Do you have rheumatoid arthritis? Yes No Do you have gout? Yes No Do you have any heart problems? Yes No Do you have any lung problems? Yes No Have you ever had a heart attack? Yes No Do you have stomach ulcers? Yes No Do you have high blood pressure? Yes No Do you have or have you had hepatitis? Yes No Do you have depression? Yes No Do you have a mental illness? Yes No Do you have any bleeding disorders? Yes No Do you have any kidney trouble? Yes No Do you have seizures? Yes No Do you have cancer? Yes No Have you ever had a stroke? Yes No Do you have anemia? Yes No If you are a woman, are you pregnant? Yes No Have you ever had a blood transfusion? Yes No Do you have HIV/AIDs? Yes No Have you ever had a blood clot in your legs or lungs? Yes No Explain all yes answers and list any other medical problems: PAST SURGICAL HISTORY: (List all surgeries you have had) TYPE OF SURGERY DATE (or approx. date) WHERE NAME OF SURGEON MEDICATIONS: (List all medications you are currently taking, including vitamins, OTC meds, herbal medications) MEDICATION STRENGTH/FREQUENCY CONDITION ALLERGIES: Are you allergic to Latex? Yes No Have you ever had a reaction to aspirin or a non-steroidal anti-inflammatory type medication?(i.e. Motrin, Ibuprofen) Yes No If yes, what was the name of the medication and what happened? Have you ever had an allergic reaction to a medication? MEDICATION Yes No If yes, please list: REACTION
3 FAMILY MEDICAL HISTORY: Do any of your relatives (immediate family, aunts, uncles, grandparents) have any of the following medical problems? Diabetes Yes No Stroke Yes No Rheumatoid arthritis Yes No Bleeding Disorders Yes No Lupus/Gout Yes No Cancer Yes No Heart problems Yes No Lung problems Yes No Anesthetic Reactions Yes No Any other medical problems Yes No Please explain all yes answers: Occupation Employer Hours Do you smoke? Yes No Cigarettes / Cigars / Other Quit? Yr How many packs per day? How many total years have you smoked? Do you use chew tobacco? Yes No Do you consume alcohol? Yes No How much/often? List any activities that you participate in on a regular basis outside of work (sports, gardening, weight lifting, musical instruments, etc.) Are you here for a work-related injury? Yes No If yes, please complete page 3 Do you have an attorney regarding this injury? Yes No If yes, who? Do you regularly attend religious services? Yes No How important is religion/spiritual issues in your life? Very Moderately Somewhat Not important Patient Expectations Please check the box the most appropriately describes your current expectations for treatment. Definitely non-surgical Probably non-surgical Not sure Either surgical or non-surgical Probably surgical Definitely surgical Please check off which factors most influence your decision to seek treatment. (Check all that apply) Pain the limits daily activities/work Pain that limits sporting activities Pain that limits shoewear I am unhappy with the appearance Concerns about long term damage to the bones/joint/ligaments Friends/family recommended I seek treatment Directed by workman s comp or an attorney
4 Review of Systems General Musculoskeletal Cardiopulmonary Weight Change Weakness Chest pain Fever / Chills Swelling Short of breath: Fatigue / Malaise Stiffness (in am) Exertional Weakness Back Pain Laying down Overall status: Joint Pain At Night Palpitations Wheezing Neurological Endocrine Dizzy Upon Standing Normal Normal Passing Out Fainting Flushing Leg/Calf Pain: Seizures Neck Mass With Exercise Neck Pain With Walking Gastro Intestinal HEENT Skin Ulcer Headache Itching Nausea / Vomiting Blurred Vision Eczema Heartburn (GERD) Ringing In Ears Psoriasis Vomit Blood Nasal discharge Dermatitis Abdominal Pain Bloody Nose Keloids Constipation Sore Throat Rashes Diarrhea Hoarseness Sores Psychiatric Genito Urinary OB/GYN Personality Disorder: Blood in Urine Menstrual cycle: Flank Pain Normal Depression/Anxiety Kidney Stones No Period Bipolar Disorder Excessive Drug abuse Signature: Date: / /
5 COMPLETE THIS SECTION ONLY IF YOU ARE HERE FOR A WORK-RELATED PROBLEM Your answers to these questions are very important. Please take the time to be as accurate and as specific as possible. WORK HISTORY: What is your current occupation? What company do you currently work for? When did you first start working for this company? If you are no longer working for this company, when did you last work for this company? Are you currently working your regular job? Yes No If so, are you on light duty? Yes No If you are on light duty, what are your work restrictions? What was your occupation when you developed the problem that you are being seen for? What company were you working for when you developed this problem? How many hours a day do you (or did you) work? How many hours a week do you (or did you) work? Have you have prior injuries or treatment for the same joint/extremity that you are being seen for? If so, when? Describe your job in detail (the job you were working when you developed your problem): What percentage of your day is standing? What percentage of your day is sitting? How much walking is required? Do you climb, work on ladders, or work at heights? How much do you lift? How Frequently? Additional Comments: Do you have a second job? Yes No If yes, please describe what you do and list how many hours per day and week you work there: PAST WORK HISTORY: Please list the type of work you did before you worked for the company you were working for when you developed this problem: Where did you work? How long did you work there? (from when to when) What did you do? Additional Comments: Signature: Date: / /
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