NEW PATIENT INTAKE FORM
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- Clementine Hopkins
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1 WILLIAM S. CRAWFORD, MD NEW PATIENT INTAKE FORM Patient Name: DOB: INSTRUCTIONS: Please complete the following questionnaire before you see the doctor. Answer each question in as much detail as possible. Write additional information on the back if necessary. 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. Would you be interested in taking part in a research study? Who referred you to Dr. Crawford, or how did you hear about us? What brought you to see Dr. Crawford today? When did your symptoms FIRST begin? (Date if known) Have you seen another doctor for this issue? If yes, who, when, and what treatment have you undergone? Please explain in your own words how the injury happened, and what makes your symptoms better or worse: HEIGHT: WEIGHT: ALLERGIES: Check anything listed below to which you are allergic. (_) No known allergies (_) Penicillin (_) Tetracycline (_) Sulfa (_) Morphine (_) Erythromycin (_) Codeine (_) Iodine/Betadine/Shellfish (_) Radiographic Dyes (_) Latex (_) Adhesive Tape (_) Other (Specify):
2 PHARMACY NAME & NUMBER: PREVIOUS MEDICATIONS: Please circle any of the following medications which you have taken in the PAST: Advil (Ibuprofen) Naprosyn/Aleve (Naproxen) Ultram Mobic (Meloxicam) Voltaren Indocin (Indomethacin) Aspirin Lodine (Etodolac) Toradol (Ketorolac) Arthrotec (Diclofenac) Celebrex (Celecoxib) Please list any side effects you experienced while taking any of the above (please specify) Nausea Diarrhea Gastric Ulcers Gastric Bleeding Upset Stomach Vomiting Other: Are you currently taking any of the following blood-thinning medications on a regular basis? Aspirin Coumadin Heparin Plavix Xarelto Pradaxa Lovenox Other: What medications are you CURRENTLY taking? (Please include all prescription and over the counter medications)? You may use the back of the page, if needed, to list additional medications. Medication Dose Frequency Are you involved in a pain contract? If so, with whom? PAST SURGICAL HISTORY: Please indicate the year of the surgery (_) No previous surgeries (_) Hysterectomy (_) Appendectomy (_) Lumbar laminectomy (_) Cataract Extraction (_) Mastectomy
3 (_) Heart Surgery (CABG) (_) Tonsillectomy (_) Cardiac Stent (_) Prostate Surgery (_) Gall Bladder (_) Other (specify) (_) Hernia Repair (_) Gastric Bypass PAST MEDICAL HISTORY: Check any medical problems that you have had. Indicate if the problem is current (even if it is being treated) or resolved (_) I have no known medical problems (_) Hypertension (high blood pressure) (_) Coronary artery disease (_) Peripheral vascular disease (_) Adult onset diabetes (_) Childhood onset diabetes (_) Past heart attack (_) Asthma (_) Ulcers (_) Hepatitis A / B / C (_) Cancer (_) Blood Clot (DVT / PE) (_) Blood Transfusion (year) (_) HIV/AIDS (_) Tuberculosis (_) Liver disease (_) Seizure disorder (_) Thyroid disease (_) Emphysema (_) COPD/Lung problems (_) Immune Disorder (specify): (_) Overweight (_) Osteomyelitis (_) Arthritis (where?): (_) Fibromyalgia (_) Other (specify): FAMILY HISTORY: Has anyone in your immediate family (mother, father, sister, brother, children) had any of the following? Please specify whom. (_) None (_) Hypertension (_) Hypothyroidism (_) Tuberculosis (_) Cancer (_) Heart Disease (_) Colitis (_) Seizure disorder (_) Leukemia (_) Rheumatic Fever (_) Bleeding tendency (_) Alcoholism (_) Stroke (_) Diabetes (_) Asthma (_) Other SOCIAL HISTORY: Occupation (if retired, list previous) ALCOHOL: How much alcohol do you consume? (_) I m a non-drinker (_) I Drink weekends only (_) Average 3-5 drinks/day (_) I m a recovering alcoholic (_) Average 1-2 drinks/day (_) More than 6 drinks/day (_) I drink only occasionally (_) Average 2-3 drinks/day NICOTINE: Check all that apply (_) I do not use nicotine (_) I am a former smoker: packs per day for years. I stopped in (year) (_) I am a current smoker: packs per day for years (_) I use other nicotine (dip / chew / E cigarette / vapor / gum / patch) DRUGS: Do you or have you ever used illicit drugs? (_) Recreational (_) Marijuana (_) Methamphetamines (_) Cocaine (_) Heroin (_) Other (specify)
4 REVIEW OF SYSTEMS: Have you recently experienced any of the following? General: Gastrointestinal: Weight gain Nausea Weight loss Vomiting Fever Change in bowel habits Chills Heartburn Night Sweats Respiratory: Skin: Shortness of breath Change in moles Coughing/Wheezing Rash Cardiovascular: Eyes: Chest pain Loss of vision Palpitations Double/Blurry vision Fainting Ear/Nose/Throat: Genitourinary: Hearing loss Frequent urination Nose bleeds Difficulty with urination Blood in urine Vascular: Psychiatric Swelling in legs Anxiety Blood clots Depression Confusion Musculoskeletal: Memory loss Muscle weakness Stiffness Neurologic: Joint pain Dizziness Burning/tingling The doctor will discuss your current problem with you in detail. The following questions are intended to give an overview of how it is affecting you now. Please select the best choice for each item below. Do you have pain? (_) None (_) Mild, occasional (_) Moderate, daily (_) Severe, almost always present What is your activity level? (_) No limitations, no support (_) No limitations of daily activities, limitation of recreational activities, no support (_) Limited daily and recreational activities, cane (_) Severe limitation of daily and recreational activities, walker, crutches, wheelchair, brace Footwear requirements (_) Fashionable, conventional shoes, no insert(s) required (_) Comfort footwear and/or shoe insert (_) Modified shoes or brace
5 Maximum walking distance (_) Greater than 6 blocks (_) 4-6 Blocks (_) 1-3 Blocks (_) Less than 1 block Walking surfaces (_) No difficulty on any surface (_) Some difficulty on uneven terrain, stairs, inclines, ladders (_) Severe difficulty on uneven terrain, stairs, inclines, ladders Everything I have answered is true and correct to the best of my knowledge. Patient signature: Date: THANK YOU FOR COMPLETING THIS PATIENT QUESTIONNAIRE. IT WILL BECOME PART OF YOUR PERMANENT MEDICAL RECORD WITH TEXAS FOOT & ANKLE ORTHOPAEDICS AND WILL PLAY AN IMPORTANT PART IN UNDERSTANDING YOUR CURRENT SITUATION AND FOLLOWING YOU IN THE FUTURE.
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New Patient Questionnaire
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Patient: First Name Middle Initial Last Name. Date of Birth SSN. Address . City State Zip Code. Home Phone ( ) Cell Phone ( )
PATIENT DEMOGRAPHICS PATIENT INFORMATION Patient: First Name Middle Initial Last Name Date of Birth SSN Gender: Male Female Address Email City State Zip Code Home Phone ( ) Cell Phone ( ) Occupation Employer
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