Patient Name: Date:_. MR#: --,.- ROY SANDERS MD - PATIENT HISTORY-ADDITIONAL PAGE PATIENT INFORMATION 4/24/2014 1
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1 Patient Name: ate:_. MR#: --,.- ROY SANERS M - PATIENT HISTORY-AITIONAL PAGE PATIENT INFORMATION Primary Physician Information Family/Primary Physician: Family/Primary Physician address and phone #: Who referred you? Patient: octor: Friend: Advertislno: Other: Marital Status: Handed: Height/Weight Occupation: single right Height (ft) married left Height (in) divorced both ' widowed Sex: Male Female Current Work Status: O em lo ed O O retired O Have you seen a doctor in the past for this problem or iniurv? If yes, who and when? 4/24/2014 1
2 Patient Name: ATE: MR#: GENERAL NEW PATIENT HISTORY CURRENT INJURY /PROBLEM What is the MAIN injury /problem you are seeing the doctor for today? IF UNLISTE CHOOSE THE CLOSEST. right shoulder left shoulder head right arm left arm neck right elbow left elbow chest right forearm left forearm midback right wrist/hand left wrist/hand low back right hip left hip Problems walking right thigh left leg Weakness, numbness, tinqlinq right knee left knee Other right calf left calf right foot/ankle left foot/ankle If more than one injury/problem, which is worse? SELECT ONLY ONE - IF UNLISTE CHOOSE THE CLOSEST. 0 right shoulder 0 left shoulder 0 head 0 right arm 0 left arm 0 neck 0 right elbow 0 left elbow 0 chest 0 right forearm 0 left forearm 0 midback 0 right wrist/hand 0 left wrist /hand 0 low back 0 right hip 0 left hip 0 Problems walking 0 right thigh 0 left thigh 0 Weakness, numbness, tingling 0 right knee 0 left knee 0 Other 0 right calf 0 left calf 0 right foot/ankle 0 left foot/ankle Is your problem a result of an injury /problem? Yes o o No 8/6/2013 1
3 Patient Name: ATE:, MR#:. _ Please describe your current problem. IF YOU ARE SEEING THE OCTOR FOR MULTIPLE PROBLEMS, ANSWER FOR THE MOST SEVERE: 0 New injury or problem (less than 6 weeks duration) 0 Subacute problem ( 6 week - 3 months duration) 0 Chronic problem (problem has been treated over time period of more than 3 months and never been restored to normal) 0 Re-injury What caused your injury /problem? Fall Lifting Throwing Reaching Pulling Fighting Twisting Sports Collision/Contact Other If the problem/injury is a result of an injury, where did it occur? at home at work via a motor vehicle accident while exercising at a sport competition other Other cause of lnlurv /problem; Other: Check any of the following that happened at the time of your injury /problem: Felt pain Had swelling Fracture o l Bruising Heard popping islocation eformity Have you had surgery related to the problem you are being seen for today? 0 Yes 0 No 8/6/2013 2
4 I... Patient Name ATE MR# What conservative treatment have you had on or since your lnlurv/problern began? Injection Chiropractic care Aspiration Bracing Physical Therapy Heat Exercise Ice Anti-inflammatory medication Massage Pain medication Rest ate you began conservaffve treatment Have you received non-surgical Are you receiving or have you treatment for at least 3 months for this applied for worker compensation problem? concerning your problem/injury? 0 Yes 0 Yes 0 No 0 No Have you talked to a lawyer Is your problem the result of an concerning your problem/injury auto accident? 0 Yes 0 Yes 0 No 0 No PAIN continuous/constant o O o 1 4 O 5 o 6 O 7 o 8 o 9 o 10 0 never occasionall 0 What time of day is Check the works that best describe the character your pain worst? of the pain you are having today: 0 morning 0 aching 0 nagging 0 shooting 0 afternoon 0 burning 0 numb 0 tender 0 evening 0 exhausting 0 throbbing 0 unbearable 0 nighttime 0 gnawing 0 sharp 0 all the time 0 miserable 0 stabbing 8/6/2013 3
5 Patient Name: ATE: MR#: What makes your symptoms better? rest sitting sports/ exercise medication standinq brace/cane/crutch ice walking sleeoina heat souottlno physical therapy lying down stretchina iniection nothing in particular Other factor that makes the pain better: What makes your symptoms worse? lying down stooping/ pushing bendina sittinq lifting pulling standina souottlno workino walking stairs nothing in particular sports/ reaching exercislno twisting/pivoting overhead activity activity in aeneral Other factor that makes the pain worse: REVIEW OF SYSTEMS General E"es ENT & Mouth Pulmonary (lungs} none none none none recent weight gain difficulty difficulty shortness of breath seeing hearing recent weight loss Loss of nose bleeds dry cough vision appetite change double swallowing productive cough vision difficulty (sputum) difficulty sleeping blurred Sinus bronchitis vision problems Fevers asthma Problems walking sleep apnea (balance problems, fallina l Night sweats 8/6/2013 4
6 Patient Name: ATE. MR#. Gastrointestinal Genitourinary Musculoskeletal Hemafopoietic/Lymphatic No issues No issues No issues No issues heartburn/ burning on urination joint pain anemia lnqestlon difficulty frequency of joint deformity lymph node swallowinq urination enloroernent stomach pains difficulty starting joint swelling or frequent infections urine warmth ulcers wetting pants or joint stiffness excessive bleeding bed nausea/ bloody urine muscle pain blood clots vomitlno diarrhea sexual difficulties weakness hemorrhoids neck pain rectal bleeding back pain black bowel Skin Neurologic movements change in bowel No issues No issues Psychiatric habits constipation ecchymotic headaches No issues frequent laxative purulent drainage dizziness anxiety use (pus) jaundice or swollen blackouts depression hepatitis liver trouble Erythematous (red) numbness and difficulty sleeping tinolino gallbladder rash paralysis appetite changes problems itching convulsion/seizur confusion es easy coordination memory loss brulsinq/bleedinc trouble slow healing been seen by a psychiatrist Endocrine/Metabolic Cardiovascular No issues No issues leg cramps (when walking) diabetes high blood pressure fainting goiter chest pain coldness in hands and/or feet thyroid problem heart attack loss of hair on arms or legs sterility palpitations (irregular heart beat) abnormal color (blue, white, red) in hands or feet cholesterol / lipid heart failure other problem 8/6/2013 5
7 Patient Name: ATE: I O I edema (leg swelling) MR#: MEICAL CONITION HISTORY Medical Condition History: NO MEICAL PROBLEMS epression Alcoholism Gout Anemia HIV Anxiety Hypertension (High Blood Pressure) Asthma Hypercholesterolemia ( Elevated Cholesterol) Arthritis -inflammatory Hypothyroidism (rheumatoid) Arthritis - osteo, Kidney isease degenerative Bowel disease Liver isorder (Cirrhosis, Hepatitis) Cancer Lung isease (COP, emphysema) Cardiac Arrhythmia Osteomyelitis (Abnormal heart rate) Congestive Heart Failure Parkinson's Coronary Artery isease Ulcer isease (Angina) Cerebrovascular isease Other (Stroke) iabetes Other Medical Condition: Have you ever had a blood clot? 0 I Yes I 0 I No Have you every had a blood transfusion? 0 I Yes I 0 I No 8/6/2013 6
8 Patient Name: ATE: MR#: SURGERY /PROCEURES Arthroscopy Fracture Repair right shoulder left shoulder right shoulder left shoulder right elbow left elbow right arm left arm right wrist/hand left wrist/hand right elbow left elbow right hip left hip right forearm left forearm right knee left knee right wrist/hand left wrist/hand right foot/ankle left foot/ankle right pelvis left pelvis right hip left hip Joint Replacement Surgery right femur {thiqh) left femur {thiqh) left knee right shoulder left shoulder right knee right elbow left elbow right tibia/fibula left tibia/fibula right wrist/hand left wrist/hand right left right hip right knee left hip foot/ankle left knee Spine Surgery foot/ankle right foot/ankle left foot/ankle Cervical I O I Thoracic I 0 I Lumbar Other Orthopedic Suraerv Non Orthopedic Suraeries abdominal surgery hernia repair brain surgery plastic surgery cancer surgery sinus surgery cardiothoracic surgery tonsillectomy eye surgery urology surgeries gallbladder surgery vascular surgery gynecologic surgery other Other Suraeries 8/6/2013 7
9 Patient Name: ATE:. MR#:. _ FAMILY MEICAL HISTORY Please check all diseases for which you have a family history: Arthritis, Rheumatoid (inflammatory) Arthritis, egenerative Cancer - Breast Cancer - Prostate Cancer - Other ementia iabetes Heart isease High Blood Pressure High Cholesterol Lung isease Stroke Other Other diseases: 8/6/2013 8
10 Patient Name: ATE:,MR#: _ SOCIAL HISTORY Current Level of Exercise: Employment: Education: Full Time Grade School do not regularly exercise Part Time High School/ Equivalent once per week Retired Some College 3-5 times per week Student College egree daily Unemployed Graduate egree isabled Alcohol: Tobacco: 0 Never use alcohol 0 I use chewing tobacco 0 Used to drink but stopped 0 I have never smoked tobacco 0 Rarely drink alcohol 0 I used to smoke tobacco (<1/monthl but stopped 0 rink occasionally 0 I currently smoke less than ½ ( 1-4/month l oack per day 0 rink socially ( 1-2/week) 0 I currently smoke ½-1 pack a day 0 rink frequently (3-5/week) 0 I currently smoke 1-2 packs a day 0 rink daily ( 1 /day) 0 I currently smoke more than 2 oacks a day ruqs: o not use drugs cocaine marijuana other Other drugs: 8/6/2013 9
11 Patient Name: ATE:,MR#:. _ MEICATIONS AN ALLERGIES Are you currently takina any medications? 0 I Yes lo I No Patient Current Medications: Medication Name ose For what purpose? o you have any alleraies? 0 I Yes lo I No Please list all allergies (including iodine and contract dves): Allergy Severitv 1 o Mild o Moderate o Severe 2 o Mild o Moderate o Severe 3 o Mild o Moderate o Severe 4 o Mild o Moderate o Severe 5 o Mild o Moderate o Severe 6 o Mild o Moderate o Severe 7 o Mild o Moderate o Severe 8/6/
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