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ORTHOPEDIC HISTORY

Name: _________________________________________

Todays Date: ________________

Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs


Primary Doctor Name and Address:

Referring Doctor Name and Address:

______________________________________

______________________________________

______________________________________

______________________________________

If not referred, how did you choose this office? ____________________________________________


Why are you seeing the doctor today? (body part) __________________________________________
How long has the pain/problem been present? _____________________________________________
Has the pain/problem worsened recently? No Yes, how recently?________________________
What started the pain/problem? ________________________________________________________
Quality of the pain: Sharp Burning Dull Aching
How severe is the pain at the location described above?
No Pain

Mild

Moderate

Severe

What makes the pain/problem better? ___________________________________________________


What makes the pain/problem worse? ___________________________________________________
Is the pain (check all that apply): Continuous Activity Related Night Pain Unpredictable
Did this problem start at work? ________________________________________________________
Have you already filed or will you file a Workers Compensation claim? _______________________
Have you missed work because of this problem? __________________________________________
What ever treatments have you tried?
Physical Therapy/Exercise

TENS unit

Narcotic medications

Cass/boot

Massage/Ultrasound

Traction

Anti-Inflammatories

Orthotics

Manipulation

Surgery

Steroid injections

Braces

Are you right hand ___

or left ___?

Previous physicians seen for this problem


Physician

Specialty

City

Treatment

ORTHOPEDIC HISTORY

Medications take for this problem


Name of Medication

Dose

Reason

X-Rays and Tests for this problem:


Results

Date

Location

X-Rays
MRI
CT Scan
Bone Scan
Other
Because of this problem, have you filed or do you plan to file a lawsuit? Yes

No

If you are a new patient to our practice, please complete the Comprehensive Health History. If you
have previously completed a Comprehensive Health History during a visit to our practice, have there
been any changes to your medical history, surgical history or medications since that time? Please
describe any changes below:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Responsible partys signature :____________________________________

FOR OFFICE USE ONLY


I have read and confirmed the above information with the patient.
X __________________________________________________

Alton Orthopedic Clinic


#4 Memorial Drive Building B, Suite 130 Alton, IL 62002
John Stirnaman MD - Board Certified Orthopedic Surgeon
Michael Taylor MD - Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD - Rheumatologist
Donald LeMoine PA-C

COMPREHENSIVE HEALTH HISTORY


Name: _________________________________________
Todays Date: ________________
Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs
Primary Doctor Name and Address:

Preferred Pharmacy (Address/Phone)

______________________________________

______________________________________

______________________________________

______________________________________

PAST MEDICAL HISTORY: Check all that apply

None Apply

Heart attack

Asthma

Rheumatoid arthritis

Depression

Heart failure

Tuberculosis

Osteoarthritis

ADHD

Abnormal heartbeat

Emphysema

Gout

Seizures

High blood pressure

Thyroid

Osteoporosis

Migraine

Stroke

Stomach ulcers

Cirrhosis

Cerebral palsy

Blood clots in leg

Gastric reflux

Hepatitis (A, B or C)

Downs syndrome

Blood clots in lung

Hiatal hernia

HIV/AIDS

Spina bifida

Poor circulation

Kidney failure

Bleeding disorder

Neurofibromatosis

High cholesterol

Kidney stones

Anemia

Neuropathy:

Hands or

Feet

Cancer: _________________________________________________________(type/treatment)
Diabetes: year diagnosed __________
Currently controlled with

insulin

oral medications

diet

Other: __________________________________________________________________________
__________________________________________________________________________________
PAST SURGICAL HISTORY:
Operation

No Prior Surgery
Date

Surgeon/Hospital

Have you every had general anesthesia?


No
Yes
If yes, have you had any problems related to this? No
Yes
Please explain any problems related to general anesthesia: ___________________________________
__________________________________________________________________________________

Alton Orthopedic Clinic


#4 Memorial Drive Building B, Suite 130 Alton, IL 62002
John Stirnaman MD - Board Certified Orthopedic Surgeon
Michael Taylor MD - Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD - Rheumatologist
Donald LeMoine PA-C

COMPREHENSIVE HEALTH HISTORY

MEDICATIONS (prescribed and over the counter):


Name of Medication

Dose

ALLERGIES TO MEDICATIONS:

No Allergies

Name of Medication

I take no medications
Reason

Reaction (rash, swelling, stomach upset, etc.)

METAL ALLERGIES:

No Allergies

YES_______________________________(List Metals)

SOCIAL HISTORY:
Work status
Working

Homemaker

Unemployed

Disables

On Leave

Retired

Student

Occupation_________________________________________________________________________
Marital Status:
Children

No

Single

Married

Divorced

Widowed

Yes, How many? ______

Do you live alone? ______ If no, who lives with you? ______________________________________
Are you currently smoking?_____ If yes, how many packs a day?___ For how many years?_______
How many packs a day did you previously smoke? ___ Other forms of tobacco? ________________
Never
Rare
Social
Frequently (more than twice a week)
Alcoholic
Recovering Alcoholic
Never
In the past
Currently Types of Drugs_____________________
Illegal Drug Use
Alcohol Use

Alton Orthopedic Clinic


#4 Memorial Drive Building B, Suite 130 Alton, IL 62002
John Stirnaman MD - Board Certified Orthopedic Surgeon
Michael Taylor MD - Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD - Rheumatologist
Donald LeMoine PA-C

COMPREHENSIVE HEALTH HISTORY

FAMILY HISTORY: Check all that apply

None Apply

Heart problems

Diabetes

Arthritis

Bleeding problems

Seizure

Cancer

High Blood Pressure

Stroke

Gout

Kidney problems

Lung problems

Mental Illness

Alcoholism

Blood clots (legs or lungs

Other: _____________________________________________________________________________
REVIEW OF SYSTEMS: (In the past 30 days have you experienced any of the following?)
Fever

Sleep apnea (snoring)

Nausea

Chills

Hoarseness

Vomiting

Weight loss

Cough

Diarrhea

Vision changes

Trouble swallowing

Constipation

Vision changes

Chest pain

Hemorrhoids

Glasses/Contacts

Palpitations

Stomach pain

Hearing loss

Swollen ankles

Urinary difficulty

Dizziness

Shortness of breath

Anxiety

Ear pain

Seasonal allergies

Hyperactivity

Nosebleeds

Skin rashes

Memory loss

Toothache

Swollen glands

Blackouts

Gum problems

Poor appetite

Headache

I have not experienced any of the above symptoms in the last 30 days
Other: __________________________________________________________________________
__________________________________________________________________________________

FOR OFFICE USE ONLY


I have read and confirmed the above information with the patient/family:
Physician Signature:_______________________________________ Date:_______________________

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