New Patient Questionnaire KNEE Alejandro Gonzalez Della Valle, MD

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Transcription:

New Patient Questionnaire KNEE Alejandro Gonzalez Della Valle, MD Name: DOB: Date: Height: Weight: Age: Chief Complaint Laterality Left Right Both Please describe your symptoms: (Mark all that apply) Throbbing pain Radiating pain Dull pain Sharp pain Catching/Locking Swelling Stiffness Instability Other: Where is the pain located in your knee? (Mark all that apply) Front Back Inside Outside Other: Current Pain Level (no pain 0 10 highest) While Walking While negotiating stairs At rest (sitting, lying down, sleeping) When did this condition start? How did it start? What makes the pain better? What makes the pain worse? Have you EVER tried any prior conservative treatment? How long? Did it help? Acupuncture or holistic remedies Arthroscopic surgery Brace / Cane / Crutches / Walker Cortisone injections Dietary supplements Viscosupplementation (Gel injections) NSAIDS (eg: Ibuprofen, Aspirin, Naproxen, Celebrex, Voltaren) Narcotics Physical therapy Weight loss Exercise program Activity modification / Lifestyle change Version 18 Dated: 6/8/2016

Functional Assessment What distance are you able to walk? Unlimited 10-20 blocks 5-10 blocks < 5 block House bound Unable How do you climb UP stairs? Normally With handrail for balance With handrail to pull myself up Unable How do you climb DOWN stairs? Normally With handrail for balance With handrail to support myself Unable What type of support do you use for walking? None Cane(s) Crutch(es) Walker How do you get out of a chair? Normally Arm rest for balance Arm rest to push myself Unable Are you able to use public transportation? Yes No Do you find this situation to be: Acceptable KOOS, JR Knee Survey Unacceptable Instructions: This survey asks for you view about your knee This information will help us keep track of how you feel about your knee and how well you are able to do your usual activities Answer every question by ticking the appropriate box, only one box for each question If you are unsure about how to answer a question, please give the best answer you can Which Knee: Left Right Both Stiffness: Amount of joint stiffness you have experienced the last week in your knee Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint 1 How severe is your knee stiffness after first wakening in the morning? Pain: What amount of knee pain have you experienced the last week during the following activities? 2 Twisting/pivoting on your knee: 3 Straightening knee fully: 4 Going up or down stairs: 5 Standing upright: Function, daily living: The following questions concern your physical function By this we mean your ability to move around and to look after yourself For each of the following activities, please indicate the degree of difficulty you have experience in the last week due to your knee 6 Rising from sitting: 7 Bending to floor/pick up an object: Version 18 Dated: 6/8/2016

Medications: Please list the medications that you CURRENTLY take 1 2 3 4 5 6 7 8 Medication Route (oral, injection, etc) Dose Frequency Allergies: Please include any known allergies 1 2 3 4 5 Allergy Reaction Are you allergic to iodine? Are you allergic to latex? Are you to metal, jewelry, or nickel? Medical History Please select any past or current medical conditions below: Anxiety Depression Kidney disorder Pulmonary embolus Arrhythmia (Irregular heartbeat) Diabetes Low acting thyroid Reflux Asthma Heart attack Open wounds/ulcers Rheumatoid arthritis Bleeding problems Heart failure (CHF) Osteoarthritis Seizures Blood clots (DVT-PE) High blood pressure Osteoporosis Stomach ulcers Cancer High cholesterol Coronary artery disease Peripheral vascular Stroke disease Infection Pneumonia Other: Surgical and Hospitalization History 1 2 3 4 5 Previous operation/hospitalization Occurrence date (approx) Have you ever had a problem with anesthesia? Problem: Have you ever had complications from prior surgery? Problem: Version 18 Dated: 6/8/2016

Family History What medical problems run in your direct family? Family member Problem Alive/Deceased Father Mother Brother Sister Grandfather Grandmother Social History Are you a tobacco user? If yes, what? Do you consume alcohol? If yes, what kind? Recreational drug use? If yes, what drug? How much? Drinks per week? How much and how often? List any recreational activities / sports that you enjoy: What do you do for a living? With whom do you live? Screening Questions (Coordination of Care) Are you currently on any blood thinners? Have you ever had a MRSA Infection? Do you have any of the following medical devices? (Mark all that apply) Pain Pump Neurostimulator Pacemaker and/or Defibrillator Shunt for hydrocephalus Do you have diabetes? If yes, do you have an insulin pump? Have you been taking opioids for 6 months or more (eg codeine, percocet, morphine, Vicodin, etc)? Immunizations and Falls Screening Have you received the pneumonia vaccine? If yes, date? If not, why? In the past year, did you received the Influenza (flu) vaccine between October 1st and March 31st? If yes, date? Have you fallen 2 or more times within the past year, or fallen with injury in the past year? If yes, do you have vision problems that may have contributed to your fall? Version 18 Dated: 6/8/2016

Review of Systems Are you currently having, or have you had any of these problems in the past year? (Select all that apply): Constitutional Hematologic Respiratory Skin Chills Easy bruising/bleeding Increased sputum Sores/ulcers Fever Blood clots in legs Cough Itching Sleep difficulty Blood clots in lungs Difficulty breathing Dryness Fatigue Wheezing Hives Night sweats Excessive snoring Rash Weight Change Mole changes ENT Cardiovascular Endocrine Musculoskeletal Double vision Chest pain Cold intolerance Joint pain Headaches Leg swelling Heat intolerance Arthritis Hearing loss Palpitations Excessive thirst Muscle pain Cataracts Poor circulation Excessive hunger Joint swelling Glaucoma Cold hands Muscle cramps Dry eyes Cold feet Muscle weakness Sinus problem Joint stiffness Gastrointestinal Genitourinary Neurological Psychiatric Abdominal pain Bladder incontinence Seizures Depression Trouble swallowing Blood in urine Dizziness Anxiety Heartburn Urinary difficulty Weakness Mood swings Nausea Painful urination Loss of balance Memory problems Vomiting Urinary retention Numbness Nervousness Constipation Urinary urgency Paralysis Insomnia Eyes Environmental Allergies Mouth Dryness Pollen Bad breath Discharge Dust Mites Bleeding gums Double Vision Pets/Animals Sores ulcers Pain Mold/Mildew Dental problem Redness Metal Loss of taste None None None Version 18 Dated: 6/8/2016

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