Florida Orthopaedic Institute Urgent Care

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Florida Orthopaedic Institute Urgent Care

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Date: Florida Orthopaedic Institute Urgent Care Patient Questionnaire Initial Evaluation Patient Name: MR# (Office Use only): Family/Primary Doctor: Phone: Family/ Primary Doctor Address: Who referred you to FOI Urgent Care? : _ Instructions: Please complete the following questionnaire before you see the doctor. Circle the word or phrase that best describes your situation. You may select more than one answer per question. Answer the question in as much detail as possible. Write additional information in the margins. The information you provide will help your doctor/pa/arnp to more accurately understand your problem(s) and develop an appropriate plan of treatment for your care. Thank you! Age: Sex: Marital Status: Dominant Hand Right/Left: Height: Weight: Occupation: What are you being seen for today? When did the problem start or injury occur? Is this Injury work related? Yes/ No Have you seen a doctor in the past for this problem or injury? Yes/No If yes when Explain in your own words how this Injury occurred: What Treatment have you had? What makes it feel better? What make it feel worse? What is your pain level today? Rate from 1-10: 1(very little) 10(extreme) Would you be interested in taking part in a research study? Yes/No

Tell us about yourself and your past medical history: Circle anything listed below to which you are allergic: (A) No know allergies (B) Penicillin (C) Tetracycline (D) Sulfa (E) Morphine (F) Erythromycin (G) Codeine (H) Iodine/ Betadine (I) Radiographic Dyes (J) Adhesive Tape (K) Other Specify Circle any of the medical problems listed below that you have now: (A) I have no known medical problems (N) Seizure disorder (B) Coronary artery disease (O) Thyroid Disease (C) Peripheral vascular disease (P) Emphysema (D) Adult onset diabetes (Q) C.O.P.D. / Lung problem (E) Childhood onset diabetes (R) Immune disorder (F) Past heart attack (S) Overweight (G) Asthma (T) Osteomyelitis (H) Ulcers (U) Blood Clot (DVT) (I) Hepatitis A/B/C (V) Osteoporosis (J) Cancer (W) Other Specify (K) Tuberculosis How much Alcohol do you consume? (A) I m a non-drinker (B) I m a recovering alcoholic (C) I drink only occasionally (D) I drink weekends only (E) An average of 1-2 drinks per day (F) An average of 2-3 drinks per day (G) An average of 3-4 drinks per day (H) More than 6 drinks per day Do you now, or have you ever smoked cigarettes? (A) Yes, I am currently a smoker I smoke (Circle one) 1 2 3 packs/per day I have smoked for years. (B) No, But I used to smoke. (C) No, I have never smoked. Do you now, or have you ever used drugs? (A) Recreational (B) Cocaine (C) Marijuana (D) Other Specify Has anyone in your immediate family ever had any of the following? Circle illness that apply. (A) None known (I) Hypothyroidism (B) Cancer (J) Colitis (C) Leukemia (K) Bleeding tendency (D) Stroke (L) Asthma (E) Hypertension (M) Tuberculosis (F) Coronary artery disease (N) Seizure disorder (G) Rheumatic fever (O) Alcoholism (H) Diabetes (P) Other Specify Have you ever had a blood clot? Yes / No

Circle any surgeries listed below you may have had. Indicate the year of the surgery. (A) No previous surgeries (G) Hysterectomy (B) Appendectomy (H) Lumbar Laminectomy (C) Cataract extraction (I) Mastectomy (D) By-pass/ Open heart (J) Tonsillectomy (E) Gall bladder (K) Prostate surgery (F) Hernia repair (L) Other Specify Any previous broken bones? Blood transfusion? Yes/ No Year: What medications are you currently taking? Please include both prescription and non-prescription medications. Medications Dose #Times a day Please circle any anti-inflammatory medications listed below which you have taken in the past. Please include all prescription and non-prescription medication and samples. Advil Arthrotec Daypro Ibuprofen Lodine Naprelan Naproxen Oruvail Tylenol Ultram Other: Please circle any of the following side effects while you were currently taking any of the above antiinflammatory medications, Nausea Diarrhea Gastric Ulcers Upset stomach Vomiting Other: Are you currently taking any of the following on a regular basis? Aspirin Axid Coumadin Cytotec Heparin Maalox Mylanta Pepcid Prevacid Prilosec Tagamet Zantac

TELL US ABOUT YOUR HEALTH IN GENERAL: Do you have any of the following? Circle YES or NO. SYMTOMS COMMENTS Chest pain Yes No Dizziness Yes No Dry cough Yes No Productive cough Yes No Difficulty breathing Yes No Irregular heartbeat Yes No Swelling in the legs Yes No Lack of appetite Yes No Nausea Yes No Vomiting Yes No Diarrhea Yes No Constipation Yes No Abdominal Cramping Yes No Varicose veins Yes No Bruising Yes No Bleeding Yes No Nose bleeds Yes No Joint pain & or stiffness Yes No Muscle pain or cramps Yes No Difficulty seeing Yes No Difficulty hearing Yes No Difficulty swallowing Yes No Difficulty sleeping Yes No Everything I have answered is true and correct to the best of my knowledge. Patient Signature Date

Patient Name: Date: MR# Preferred Pharmacy Information Pharmacy Name: Pharmacy Street Address: City, State, Zip: If address is unknown, Please provide crossroads: Pharmacy Phone number: Everything I have answered is true to and correct to the best of my knowledge. Patient Signature Date Thank you for completing this patient questionnaire. It will become a part of your permanent medical record at Florida Orthopaedic Institute

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