NEW PATIENT MEDICAL QUESTIONNAIRE

Transcription

1 NEW PATIENT MEDICAL QUESTIONNAIRE Ronald W. Lindsey, MD, FAAOS, FACS Professor and Chair Orthopaedic Trauma and Spine The John Sealy Distinguished Centennial Chair in Rehabilitation Sciences Department of Orthopaedic Surgery and Rehabilitation University of Texas Medical Branch Shibi Abhilash Kunjumon, MSN, FNP-C Nurse Practitioner Jessica Lamphere, RN, FNP-C Family Nurse Practitioner Department of Orthopaedic Surgery and Rehabilitation University of Texas Medical Branch UTMB at League City Campus Clinics 2240 Gulf Freeway South Suite League City, TX Phone: Fax: CLINIC & OFFICE LOCATIONS: UTMB Orthopaedic Clinic at South Shore Harbour 3023 Marina Bay Drive Suite 101 League City, Texas Phone: Fax: UTMB DOSR-Admin Office 301 University Blvd Galveston, Texas Fax: Monica Cooper: & Carolyn Woodward:

2 Today's Date: / / I. PERSONAL DATA NEW PATIENT MEDICAL QUESTIONNAIRE Name: DOB: Age: Sex: Race: Height: Weight: Cell # Home # Work # address(s): If we need to get in touch with you regarding and appointment change and/or in case of an emergency, who may we call? Please provide name and phone number(s). or II. SOCIAL DATA Marital Status: Number of Years: Children: Ages: Do you drink? How often? How much? Do you smoke? Packs/day? Do you now or have you ever used street drugs? What hobbies do you have? III. EMPLOYMENT DATA Job/Profession: Are you currently employed? Employer: How long have you worked at this particular job? Do you plan to return to work? If so, when would you like to return? Are you currently receiving compensation? If so, from what source? Is this injury job-related? Are you currently involved in a legal case for this injury? If so, who is your attorney? Are you currently disabled? (Yes or No) 2

3 If yes, are you seeking treatment in hopes of eliminating disability? IV. CURRENT MEDICAL HISTORY What, specifically, is your injury or complaint? When did this injury and/or symptoms first occur? Please describe the events leading to this injury or these symptoms: Please describe your symptoms, their location, and how often they occur: Has your condition prevented you from participating in any of your normal activities? If so, please list these: Have you had any of the following tests and when? MRI EMG/NCS Myelogram CAT Scan Discogram Bone Scan If surgery has been performed for your condition, what procedure and when? Was there ever a period following surgery when your symptoms were improved? If so, please describe: Were you advised to partake in physical therapy? What treatments did you receive and when? Have you had problems with any of the following? Urination Numbness Dizziness Mobility Bowel Movement Blurred Vision Others (explain) V. PAST MEDICAL HISTORY Have you or anyone in your family ever been diagnosed with any of the following? Myself Family Member Kidney Problems Ulcer Disease Cancer Heart Disease Diabetes High Blood Pressure Depression Schizophrenia Other 3

4 VI. WHAT OTHER DOCTOR(s) HAVE EVALUATED AND/OR TREATED YOUR CURRENT CONDITION? Name: Address: Telephone: VII. CURRENT PHYSICIANS PCP/ Internist (phone) Cardiologist (phone) Pain Management (phone) Neurologist (phone) Other (phone) VIII. MEDICATIONS ffff Please note, Dr Lindsey does not prescribe medication unless and/or until he orders a study and has received the results or unless he s performed surgery on you. ffff Please list all medications, which you are currently taking: (Please attached separate sheet if needed) Medicine Date Filled Last Taken List ALLERGIES to any medications and reaction: Are you taking any blood thinners or have you taken any recently? IX. SURGERY If surgery is an option and/or recommendation, would this be a consideration? (Yes or No) If no, why not? If yes, please circle a time-frame below: <1 month 2-6 months 6-12 month >1 year If surgery was recommended, do you have a preference in hospitals? (Yes or No) If YES, where would you prefer to have surgery? Jeannie Sealy Hospital Victory Lakes (outpatient) 4

5 PATIENT PAIN DRAWING Where is your pain now? Using the drawing below, mark the area(s) where you feel the following sensations: Aching + Numbness = Pins and Needles ^ Burning * Stabbing / Please include all affected areas. On a scale of 1-10 (1 being the worst and 10 being the best, how bad is your pain now? Please mark an X on the body above where the pain is the worst now on picture. Please mark on an X on the line below how bad your pain is now: No pain Worst possible pain If you are filling out this form electronically, you may describe your symptoms here: ffff Please forward all MRI and other imaging reports with this questionnaire. 5

6 Ronald W. Lindsey, M.D. Professor and Chair The John Sealy Distinguished Centennial Chair in Rehabilitation Sciences Department of Orthopaedic Surgery and Rehabilitation The University of Texas Medical Branch Galveston, Texas (Tel) (Fax) AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) BY UTMB I hereby give my permission to Dr. Ronald W. Lindsey and UTMB to release any and all information to those parties deemed appropriate by them which may be required in connection with my treatment. I also authorize and request any physician or other person or hospital/institution by whom or in which I have been treated for injury or illness to provide Dr. Ronald W. Lindsey full information relative to such treatment of me. Print Name: Date: Signature: Date: Parent Signature: Date: (For minor age patient s only) 11/08/18 6