Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week

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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 Injury Type: Work Comp Car Accident Other Work status: Currently working Retired Unemployed Disabled prior to injury Disabled due to injury Occupation: ----------------------------------- Which of the following best describes your work related activities? Desk work Occasional lifting Light lifting Heavy lifting At this moment, which of the following best describes your non-work related activities? Inactive Occasional sports Work out 2-3x per week Work out 4-5x per week Are you receiving or filing any of the following with regard to your injury? es o Worker's compensation Disability Lawsuit Date of injury or when problem began: Is your problem the result of an injury? es o What caused your injury? Fall Reaching Collision/contact Lifting Fighting Pulling Throwing Twisting Other (specify): Check any of the following that happened at the time of your injury: Felt Pain Heard popping Had swelling Dislocation Fracture Other (specify): Check any of the symptoms you are currently experiencing: Pain Weakness Instability Restricted motion Other (specify): If your problem is the result of an injury, where did it occur? (Check one answer only) Home Work Motor vehicle accident Exercise Sport competition /A Other (specify): Page 1 of 5

3 Washington Circle W, #207/208 Have you received previous treatment for your current problem? If yes, please specify: es o Surgery Injection Physical therapy Prescription meds SAIDs Describe: Corticosteroid Hyaluronic acid Other (please describe): PT duration: Type and duration splinting: Hand therapy duration: Check the words that best describes the character of your pain today. What makes the pain better? What makes your pain worse? Aching Sharp Rest Standing Sitting Throbbing Shooting Stabbing Gnawing Tender Burning Exhausting agging Medication Ice Heat Sitting othing in particular Other (specify): Standing Lying down Walking Exercising othing in particular Penetrating umb Unbearable Other (specify): Lying down Walking Activity in general Stopping/ bending Other (specify): Page 2 of 5

3 Washington Circle W, #207/208 Allergies: Please list any allergies that you currently aware of 1. 2. 3. 4. Medications: Please list any medications you are currently taking, both prescription and over the counter 1. 2. 3. 4. 5. 6. 7. 8. Medical History: Please check all that apply Alcoholism Coronary artery Anemia disease Depression Anxiety Diabetes mellitus Arrhythmia Enlarged prostate Kidney disease Liver disease Lung cancer Obesity Osteoporosis Arthritis Asthma Bleeding disorder Breast cancer Colon cancer Congestive heart failure Chronic obstructive pulmonary disease (COPD) GERD Glaucoma Hepatitis HIV/AIDS Hyperlipidemia Hypertension Hypothyroidism Pacemaker/ AICD Peptic ulcer disease PVD Prostate cancer Seizures Stroke Other: Surgical History: Please check all that apply and specify the date for each. For previous arthroscopy, please indicate the type of surgery (e.g. meniscus repair, rotator cuff repair, etc). For joint replacement, please indicate which joint(s) Appendectomy: -------- Arthroscopy: ---------- Type: -------------- Breast surgery: -------- CABG: -------- Cholecystectomy: -------- Colon surgery: -------- C-Section: -------- Hernia repair: -------- Hysterectomy: -------- Joint replacement: Joint: Spine surgery: -------- Tubal ligation: -------- Other: : -------- Page 3 of 5

3 Washington Circle W, #207/208 Family History: Please check whether a family member has had any of the following conditions * ote: Maternal refers to your mother's side of the family; paternal refers to your father's side of the family Relationship Deceased (es/o) Alzheimer's Arthritis Asthma Cancer Diabetes Heart Disease Cholestero High Hypertension Kidney Diseases Mental Illness Stroke e Abuse Substanc Thyroid Disease Mother Father Sister Brother Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Son Daughter Other: Social History: Alcohol Use: es o Drinks per week: please enter the number of drinks associated with each type of alcohol Coffee Use: es o Coffee consumption per week: Drug Use: es o If yes, please describe type: (for example: marijuana, methamphetamines, steroids etc.) Page 4 of 5

3 Washington Circle W, #207/208 Tobacco Use (this refers to both present & past tobacco use): es o If yes, describe type: Frequency: Quit date (if applicable): Smokeless tobacco (this refers to both present and past smokeless tobacco use): es o If yes, please describe type: Frequency: Quit Date (if applicable): Review of Systems: In order to get a better understanding of your overall health, please check any of the following that you are currently experiencing General Eyes Gastrointestinal Endo/Heme/Allergies Fever Blurred vision Heartburn Easily bruise/bleed Chills Double vision ausea Environmental allergies Weight loss Eye pain Vomiting eurological Fatigue Cardiovascular Abdominal pain Dizziness Weakness Chest pain Diarrhea Tingling Skin Palpitation Constipation Tremor Rash Shortness of breath Genitourinary Seizures Itching Leg swelling Painful urination Loss of consciousness Head, Eyes, Ears, ose and Throat Respiratory Urgency Psychiatric Headaches Cough Frequency Depression Hearing loss Coughing up blood Musculoskeletal Substance abuse Ear pain Mucus production eck pain ervous/anxious Congestion Shortness of breath Back pain Insomnia Sore throat Wheezing Joint pain Memory loss Page 5 of 5

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