Thomas Kremen, MD ORTHOPAEDIC SURGERY AND SPORTS MEDICINE

Similar documents
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1

Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS

Amarillo Surgical Group Doctor: Date:

Questionnaire for Lipedema Patients

New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:

New Patient Information

Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):

Please answer all questions in blue or black ink by filling in the blank or circling. SOCIAL HISTORY

ABOUT YOU (Please print clearly) Name Birth Date Age Sex: Male Female Referring MD Mailing Address: Address

PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.

Please fill in all bubbles completely! Patient Name: Date: Date of Birth: Referring Doc: Family Doc: I. What are you being seen for today?

DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)

Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?

COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:

Past Medical History. Chief Complaint: Appointment Date: Page 1

GUPTA SPORTS & SPINE CENTER

LECOM Health Ophthalmology

New Patient Intake Form

NEW PATIENT INTAKE FORM

Providence Neurosurgery PATIENT INFORMATION SHEET

Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)

CENTRAL COAST ORTHOPEDIC MEDICAL GROUP Medical History Questionnaire GENERAL INFORMATION

New Patient Form. Patient Demographics. Emergency Information. Employment Information. Page 1 of 7. Family Health Chiropractic Care

City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,

Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone

Where is your pain located? Please use the diagram below to indicate where most of your pain is located.

Patient Name: Date of Birth:

Patient Intake Form for Allegany Ear, Nose, & Throat

WILLIAM K MONTGOMERY, MD

ANY FAMILY HISTORY OF ANEURYSM OR DVT?

The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.

725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)

MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY

Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B

New Patient Questionnaire

Chayapathy Jollu, MD Board Certified in Physical Medicine and Rehabilitation Patient Initial Pain Questionnaire

Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6

Patient History Form

Cell Phone #: Home Phone #: ** Address (prefer your forever address):

ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:

CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)

Creve Coeur Family Medicine, LLC

RHEUMATOLOGY PATIENT HISTORY FORM

PAIN INFORMATION SHEET

BIRMINGHAM VASCULAR ASSOCIATES, P.C. PATIENT MEDICAL HISTORY FORM

Medical History Form

PULMONARY MEDICINE PATIENT QUESTIONNAIRE

Welcome to About Women by Women

New Patient Medical History Intake Form

New Patient Pain Evaluation

New Patient Questionnaire. Name DOB Date

Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State

Last Name First Name Middle Name MRN

New Patient Information Form

Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone

*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

CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )

MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire

WELCOME TO OUR OFFICE

SANTA MONICA BREAST CENTER INTAKE FORM

PATIENT HISTORY RECORD FACULTY INTERNAL MEDICINE. Date of Appt: / / Name: Date of Birth: / / Last First Middle

Salt Lake Orthopaedic Clinic Initial Visit Form

Patient Medical History Form

I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.

SUSQUEHANNA HEALTH CANCER CENTER HEMATOLOGY & ONCOLOGY NEW PATIENT HEALTH QUESTIONNAIRE. Name: Date of Birth:

Cardiovascular Genetics Clinic Vascular Questionnaire

NEW PATIENT INFORMATION FORM

* CC* PATIENT QUESTIONNAIRE

NEW PATIENT FORM. Please print in ink and fill in all blanks Please fill out front and back. Patient s Full Name

NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.

Medical History Form

TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM

DIVISION OF CARDIOLOGY

Morris Medical Center, P.A.

OhioHealth Orthopedic & Sports Medicine Physicians

New Patient Questionnaire

Name: Date: Street Address: Referring Physician: How long have you had your current problem?

Name Date. Date of Birth Social Security #: Street Address. City State Zip. Home Phone Cell Phone Address. Employer Business Phone

MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History

MEDICAL DATA SHEET For Patients 18 years of age and older

BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:

Florida Hospital Spine Center Patient Intake Form

Patient Medical Information. Last. Sex: M / F Age: Date of Birth: Home Address: City: State: Zip Code: Business Address: City: State: Zip Code:

Balance and dizziness questionnaire

Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:

Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.

McLaren Cardiothoracic and Vascular PATIENT HISTORY FORM

Gender: M F Race: Caucasian African American Hispanic Other

City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week

Aspire Pain Medical Center

The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:

Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?

PATIENT HEALTH INFORMATION SHEET

NEW PATIENT VISIT QUESTIONNAIRE

Name: Date: Sex: Male Female Date of Birth(DD/MM/YY): Address: City: Postal Code: Phone #: (Home) (Work) (Cell) (Other) Address:

Joseph S. Weiner, MD, PC Patient History Form

MEDICAL QUESTIONNAIRE (male)

Premier Internal Medicine of Alpharetta, PC

Spine New Patient Questionnaire Rev

Transcription:

Thomas Kremen, MD ORTHOPAEDIC SURGERY AND SPORTS MEDICINE New Knee Patient Intake Questionnaire PLEASE PRINT Please provide your referring physician s name, address (if known, if not list the city) and phone number (if known): What problem brings you in today (circle ONE item from each line below)? Left Knee Right Knee Both Left and Right (which side is worse? ) Pain Swelling Unstable joint Decreased motion Other: Do you have any catching, locking or bones moving out of place? Yes No How long has your knee hurt? (how many days, weeks, months, or years?) Was this knee problem the result of a specific injury or no specific injury? (Generally injuries that occurred many years ago and did not causing constant disability can be considered no specific injury) Yes, my injury was: No specific injury How severe would you rate your knee pain on a scale of 1 to 10? (refer to scale below)

How would you rate your knee today as a percentage of normal (0% to 100% scale with 100% being normal)? % Ci r c l e any pr ev i ous t r eat m ent s: P h y s i c a l T h e r a p y In j e ct i o n Su r g e r y Have you taken NSAIDs? Yes No Did they help with your pain? Yes No Examples of NSAIDs: ibuprofen (advil, Motrin), Naproxen (Naprosyn/Aleve), Diclofenac (Voltaren), Meloxicam (Mobic) Where does your knee hurt? (circle or mark area below) Right Knee (front and side views) Left Knee (front and side views)

Please check all that apply: CARDIOVASCULAR Chest Pain Irregular heart beat Poor circulation Dizziness Rapid heart rate Swelling of ankles CONSTITUTIONAL Chills/fever Fainting Headache Loss of sleep Unplanned weight loss Loss of appetite Night sweats ENDOCRINE Rapid weight loss/gain Intolerance to warm room Multiple broken bones Cessation of menstrual periods Excessive hunger/thirst Loss of libido Thyroid disease Diabetes Pregnant? Low Vitamin D HEMATOLOGIC Swollen lymph nodes Easy skin bruising Prolonged bleeding from cuts, tooth extractions Blood clots in the past? Sickle cell disease IMMUNOLOGIC Autoimmune disease Rheumatoid arthritis Psoriasis Ankylosing spondylitis Are you HIV positive? Joint infections in the past Bone infections in the past Chronic infections anywhere in the body INTEGUMENTARY Skin rashes or eruptions Bruises Redness Draining wounds MUSCULOSKETAL Multiple joint pains Lower back pain Neck pain Broken bones Joint replacements NEUROLOGIC Fainting Headaches Numbness of arms or legs Electric pain in arms or legs Seizures Tingling of hands, feet, arms or legs Bowel incontinence Bladder incontinence (spilling urine abnormally) PSYCHIATRIC Anxiety Depression Panic attacks Restlessness Bipolar disease Attempted suicide in the past RESPIRATORY Cough Shortness of breath Wheezing Coughing up blood Pneumonia DENTAL: Dental infections Gum disease

Do you have any medical problems? (Example: Diabetes, Cancer, Heart attack, Stroke, high blood pressure, gastroesophageal reflux, autoimmune disease, Rheumatoid arthritis, Thyroid problems, Marfans, Ehlers Danlos) Have you ever had surgery in the past? (Example: Gall bladder removed, appendix removed, tonsils removed, broken bone surgical repair, pacemaker implanted, cancer surgery, spine surgery) Current Medications: Name of Medication Dose How often do you take it? Ex: twice a day, once a week Allergies to medications and type of reaction:

Family History of Medical Problems: If yes, explain Father: qyes qno Mother: qyes qno Grandparents: qyes qno Siblings: qyes qno Social History: Do you smoke? (includes cigars/pipes/vaping) Do you drink alcohol? Yes No If yes, how many packs per day? Yes No If yes, how many drinks per week do you drink? Do you use any other drugs? Yes No If yes, what substances do you use? How often do you use these substances? Occupation: With whom do you live currently (circle one)? Alone Parent(s) Spouse (significant other) Homeless Other: PE: PLEASE LEAVE THIS SPACE BLANK (for office use only) -------------------------------------------------------------------------------------------------------------------------------------------------------------- PLAN:

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback