Phillips Brayford Orthopaedics 48 Tunnel Rd, Suite 203 Pottsville PA Phone: Fax: PATIENT INFORMATION

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PATIENT INFORMATION Name: Date of Birth: Family Physician: Referring Physician: Height: Weight: Marital Status: Single Married Separated Widowed Divorced Employment Status: Employed Unemployed Disabled Retired Student Occupation: Sports (currently participating in): Hand Dominance: LEFT RIGHT Living Arrangements: Private residence: Lives alone Private residence: Lives with others Assisted Living Facility Extended Care Facility. Name: Is there a Power of Attorney? YES NO Name: Relationship: Phone #: REASON FOR VISIT Current Problem: Referred by: How long have you had this problem? (circle one) Number of : Days Weeks Months Years Your problem was caused by: (check one) Unsure: Auto accident: Other accident: Work Injury: Sports Injury:

Where is your pain?. PAIN What is your pain? (rank on a scale 0 to 10, 0 is no pain, 10 is worst pain) What is your pain right now? What is your pain at rest? What is your pain with activity? Is your pain: Constant Frequent Occasional Rare SYMPTOMS Please check any that apply: Back Pain Joint Pain/Stiffness Joint Swelling Numbness/Tingling Difficulty/Standing Difficult with Activities of Daily Living Fever Other: TREATMENT TO DATE Have you had any steroid injections? YES NO Date of injections: Have you been to Physical Therapy? YES NO If yes how long? Any other treatment? Have you had any of the following studies for this problem? X-ray Date: MRI Date: CT Scan Date: Do you use an assistive device? Cane Crutches Walker Wheelchair Brace Type:

No Known Allergies Phillips Brayford Orthopaedics ALLERGIES List all your allergies (including food and environmental) 1. Reaction: 2. Reaction: 3. Reaction: 4. Reaction: 5. Reaction: MEDICATIONS I do not take any over-the-counter medications. I do not take any prescription medication. List all medications including over-the-counter medications, prescriptions, and vitamins 1. Start Date: Dose: 2. Start Date: Dose: 3. Start Date: Dose: 4. Start Date: Dose: 5. Start Date: Dose: 6. Start Date: Dose: 7. Start Date: Dose: 8. Start Date: Dose: 9. Start Date: Dose: TOBACCO None Former Smoker Date of last use: Years of use: Cigarettes Cigars Smokeless Tobacco None Quit, Date of last use: ALCOHOL How many Packs/Tins per day: Yes, Type: Amount: None Quit, Date of last use: ILLICIT DRUG Yes, Type: Amount:

None Arthritis Asthma Asthma Exercise Induced Asthma Seasonal Blood disorder Cancer: Cataracts Congestive Heart Failure COPD/Emphysema CAD/Heart Disease CVD/Stroke Depression Diabetes Insulin Dependent Diabetes Noninsulin Dependent DVT/Blood Clot Glaucoma Stomach/Bowel Gout Heart Value Disease None Arthritis Asthma Blood Clots/DVT/PE Blood Disorder Cancer: COPD/Emphysema Diabetes Gastrointestinal Disorder Phillips Brayford Orthopaedics PAST MEDICAL HISTORY FAMILY HISTORY PAST SURGICAL HISTORY Heart Attack Hepatitis Type: High Blood Pressure HIV/AIDS High Lipids/Cholesterol Hyperthyroid Hypothyroid Immune Disorder Irregular Heart Rate Kidney Disease Liver Disease Muscle/Bone Pulmonary Embolism Prostate/BPH Peripheral Vascular Disorder Seizures Sleep Apnea TIA/Mini Stroke Tuberculosis Other: Heart Disease High Blood Pressure High Cholesterol Immune Disorder Kidney Disease Liver Disease Seizures Stroke/CVA/TIA Appendectomy Angioplasty Arthroscopy Back/Spine Breast CABG Carotid Endarterectomy Carpal Tunnel Release Cholecystectomy C-Section Ear Hemorrhoidectomy Hernia Repair Hip Replacement Hysterectomy Knee Replacement Shoulder Surgery T&A Thyroidectomy Wisdom Teeth Other:

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