UW Medicine. Affix Pt Label Here. Name: U Number: DOB: New Shoulder & Elbow Patient Form
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1 New Shoulder & Elbow Patient Form UW Medicine Name Date Age How did you hear about us? Requesting Physician Name UPIN # Address City State Zip Code Phone Fax Primary Care Physician Name UPIN # Address City State Zip Code Phone Fax Chief Complaint - Please describe the problem that brings you into the office today: Social History Tobacco Use Mark Only One: Never Packs per day: 0.5 Years: 5 Date quit: Types: Cigarettes Quit 1 10 Pipe Passive Cigars Yes 2 20 Snuff Chew Alcohol Use Drug use No Yes Drinks per week: # Can(s) of beer # Drink(s) containing 0.5 oz of alcohol # Glass(es) of wine # Shot(s) of liquor No Yes Use per week: IV drug use: No Yes Are you currently working? Yes No What is or was your occupation? 1
2 Family History Please check if any of your family members have had the following: ADHD Alcohol/Drug Allergic/Atopic Disease Arthritis Autoimmune Cancer Colorectal cancer Diabetes Gastrointestinal (GI) Genitourinary (GU) Heart Hypertension Lipids Osteoporosis Psych Pulmonary Stroke Thyroid Other Past Medical History 1. Do you have, or are you being treated for, any of the following (please check all that apply): Allergic rhinitis (477.9) Anxiety (308.0) Asthma (493.90) Bipolar (296.8) Bleeding/clotting disorder (286.9) Cancer (CA) (234.9) Chemical dependency Drug (304.90) Alcohol (303.9) Chronic lung disease/emphysema (COPD) (496) Congestive heart failure (CHF) (428.0) Coronary artery disease (CAD) (414.00) Depression (311) Diabetes Using insulin (IDDM) (250.01) Not using insulin (NIDDM) (250.00) Fibromyalgia (729.1) Heart attack (MI) (410.9) Hepatitis (please specify type(s)) (573.3) High blood pressure (HTN) (401.9) High cholesterol (272.4) Psoriasis (696.5) Rheumatoid Arthritis (RA) (714.0) Stroke (434.91) Transient ischemic attack (TIA) (435.9) Thyroid disorder Hypothyroidism (244.9) Hyperthryroidism (242.90) Sleep Apnea (780.57) Other Sleep disorder/trouble sleeping/(insomnia) (780.50) Ulcers Stomach ulcers (531) Peptic ulcer disease (PUD) (533) Other (specify) Heartburn (787.1) Reflux (GERD) (530.81) NO PAST MEDICAL HISTORY (1000) 2
3 Past Surgical History 1. What studies have you had for this problem? (Check all that apply) X-rays CT MRI Arthrogram Nerve Study (EMG) Bone Scan Other: 2. Have you had any previous surgeries for this problem? Yes No Surgeries for This Problem and if they helped Surgeon Year 3. List all Other Bone/Joint (Orthopedic) Surgeries. Surgeries Year 4. Please list/check all Other Surgeries you have had. Surgeries Year No previous surgeries (100) Appendix (appendectomy) (44950) Gall bladder (cholecystectomy) (47600) Bypass/open heart (CABG) (33999) Hernia Repair (49585) Hysterectomy (581550) Tonsils removed (tonsillectomy) (42820) Other Surgeries Year Musculoskeletal Neck/Chest Arthroscopy Spine Shoulder Pelvis/Hip Upper Arm/Elbow Femur/Knee Forearm/Wrist Leg/Ankle Hand/Finger Foot/Toes
4 Allergies UW Medicine 1. Do you have any allergies? Yes No if so, please list To Medications? To Foods? 2. Are you allergic to latex? Yes No 3. Are you allergic to iodine? Yes No Medications 1. Are you taking any pain medications YES NO If so, please list all: Pain Medications Dose Times per day Reason for taking 2. All other Medications Dose Times per day Reason for taking 4
5 Please Check one: Right Handed Left Handed Ambidextrous Is this a work related problem? Yes No If yes, list your OWCP Claim# or L&I Claim# If disabled, when did you last work? Is a lawyer involved with this problem? If so, name/address History of Present Illness 1. Location - where is the problem located? Right Side Left Side Both Sides Shoulder Elbow Other 2. Severity - Please rate the intensity of your joint Pain/discomfort: (1 = No Pain, 10 = Severe Pain) Context - How did this problem begin? 4. Modifying Factors - What makes your symptom(s) worse? Using affected side Work Exercise Don t know What improves your symptom(s)? Rest Ice Heat Exercise NSAIDs (anti-inflammatories) 5
6 Review of Systems Do you have or had any of the following Problems? (Check any that apply) General Eye weight gain weight gain loss fatigue glasses/contacts cataracts UW Medicine insomnia fever night-sweats/chills glaucoma Comments Ear/Nose/Throat Heart Lung Stomach Muscles/ Bones Urinary Tract Skin Neurology Mental Health Endocrine sinus trouble hearing loss irregular heartbeat high blood pressure chest pain shortness of breath difficulty breathing decreased appetite constipation heartburn arthritis fractures kidney stone bladder/kidney infections masses blisters seizures tingling anxiety depression increased thirst diabetes ringing in ears fluttering in chest coronary disease lung disease persistent cough nausea diarrhea hepatitis A B C sprains prostate problems painful urinating non-healing wounds dermatitis numbness severe headaches other (please describe) thyroid Blood/Lymph Immunological bleeding or clotting problems anemia swollen or enlarged lymph nodes hay fever HIV/AIDS lupus SANE Score How would you rate your affected and opposite extremity today as a percentage of normal (0% to 100% scale with 100% being normal)? Right Side: % Left Side: % Physician Signature Date 6
7 If you have a shoulder problem, please fill out this Simple Shoulder Test for BOTH of your shoulders. Simple Shoulder Test Please answer YES or NO for BOTH of your shoulders RIGHT LEFT YES NO YES NO 1 Is your shoulder comfortable with your arm at rest by your side? 1 2 Does your shoulder allow you to sleep comfortably? 2 3 Can you reach the small of your back to tuck in your shirt with your hand? 3 4 Can you place your hand behind your head with the elbow straight out to the side? Can you place a coin on a shelf at the level of your shoulder without bending your elbow? Can you lift one pound (a full pint container) to the level of your shoulder without bending your elbow? Can you lift eight pounds (a full gallon container) to the level of your shoulder without bending your elbow? Can you carry twenty pounds at your side with this extremity? 8 9 Do you think you can toss a softball under-hand twenty yards with this extremity? 9 10 Do you think you can toss a softball over-hand twenty yards with this extremity? Can you wash the back of your opposite shoulder with this extremity? Would your shoulder allow you to work full-time at your regular job? 12 7
8 If you have an elbow problem, please fill out this Elbow Shoulder Test for BOTH of your elbows. Simple Elbow Test Please answer YES or NO for BOTH of your elbows RIGHT LEFT YES NO YES NO 1 Is your elbow comfortable with your arm at rest by your side? 1 2 Does your elbow allow you to sleep comfortably? 2 3 Does your elbow allow you to reach the small of your back to tuck your shirt in? 3 4 Can you place your hand behind your head with the elbow straight out to the side? 4 5 Will your elbow allow you to pull on socks or stockings? 5 6 Does your elbow allow you to lift one pound to the level of your shoulder? 6 7 Can you use your arm to help you rise from a chair? 7 8 Will your elbow allow you to carry 20 pounds at your side? 8 9 Will your elbow allow you to comb your hair? 9 10 Will your elbow allow you to throw a ball with this arm? Will your elbow allow you to wash the back of your opposite shoulder? Would your elbow allow you to work full-time at your regular job? 12 8
UW Medicine. Address City State Zip Code Phone Fax
New Warme Patient Form Name Date Age Please Check one: Right Handed Left Handed Ambidextrous How did you hear about us? Requesting Physician Name UPIN # Address City State Zip Code Phone Fax email Primary
DEMOGRAPHICS. Female Weight: lbs
DEMOGRAPHICS Date of Birth: Age: years Gender: Male Height: inches Female Weight: lbs Handed: Right BMI: Left Ambidextrous Race: choose only one Ethnicity: Marital Status: African American / African Heritage
All Other Medications, Dose Times per day Reason for taking the medication. Phone #
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VASCULAR SURGERY PATIENT HEALTH HISTORY
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SURGERY SPECIALTY PATIENT HEALTH HISTORY
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For Office Use Only: MA complete Date of Visit / / mm/dd/yyyy. This form must be scanned into the medical record. Do not remove from clinic.
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*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
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3 Washington Circle W, #207/208 Patient ame: Age: Chief Complaint: Please describe what you are being seen for today: What is your hand dominance (which hand do you write with)? Left Right Ambidextrous
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Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
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GUPTA SPORTS & SPINE CENTER
GUPTA SPORTS & SPINE CENTER NEW PATIENT INFORMATION FORM -SPINE Please print all information. Thank you for your cooperation. Patient Name: Date of Birth: _ Social Security # Address: City: _ State: Zip
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
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IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM.
Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you
New Patient Medical Questionnaire DATE:
New Patient Medical Questionnaire DATE: Patient Name: DOB: AGE: Other Physicians: Who can we thank for referring you to our practice? Pharmacy Name & Location:` Phone # CHIEF COMPLAINT What problems are
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orthwest Georgia Surgical Specialists, PC Medical History Form ame Date of visit Last First MI Day ear Date of Birth Age Gender Marital Status Height Weight Day ear Referring Doctor Reason for Visit PAST
Alivia Acupuncture Clinic, LLC. Address. City State Zip. . Occupation Employer. Emergency contact Relationship. Primary Care provider Phone
Alivia Acupuncture Clinic, LLC Karla Sourasky Olmos, L. Ac Patient Information Name Age Date of birth Address City State Zip Email Home Phone Work phone Cell Phone Marital Status Single Married Divorced
Medication Allergies
**PLEASE CHECK IN 15 MINUTES PRIOR TO APPOINTMENT WITH FORMS COMPLETED** Primary Provider at Ocotillo Internal Medicine Other Physicians you see: Jonathan Hackenyos, D.O. 1. Cheryl Maurice, M.D. 2. 3.
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Date First Name Middle Name Last Name. SSN Sex Birth Date Height Weight. Marital Status Spouse Name Number of Children. Address City State Zip
PATIENT INFORMATION Date First Name Middle Name Last Name SSN Sex Birth Date Height Weight Marital Status Spouse Name Number of Children Address City State Zip Home Phone Cell Phone Email Emergency Relation
MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
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