INITIAL KNEE CONSULTATION
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- Anissa Harmon
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1 INITIAL KNEE CONSULTATION
2 NAME: AGE: DATE: SEX: MALE FEMALE HAND DOMINANCE: RIGHT LEFT HEIGHT: WEIGHT: SOCIAL SECURITY NO: - - INSURANCE: POLICY NO: REFERRED BY: PHONE NO: HOSPITAL/ ADDRESS: Which knee: Right Left Date of onset OR length of symptoms: Prior injuries to this knee: YES NO If yes, please describe: Please describe how your symptoms began (traumatic/injury OR gradual/unknown onset): Location of pain: front of knee inner knee outer knee all over If 100% were normal, as of today what percentage would you give your knee as a grade? Pain at rest (1 least - 10 greatest) Pain with activity (scale 1-10) Pain at night YES NO Activities that make the pain better: Activities that make the pain worse: Swelling YES NO Type of Pain: Sharp Dull Throbbing Numbness Shooting Burning Tingling Nature of Pain: Constant Frequent Occasional Intermittent Since onset, is the pain getting: Better Worse Does the pain radiate? Yes No If yes, where: Groin Back Hip Thigh Calf Foot Symptoms are worse in: Morning Afternoon Night Same all day Any mechanical symptoms: None Popping Clicking Locking Giving way Instability Do you feel that you limp: No limp Slight Moderate Severe Do you use assistive devices: None Cane Crutches Walker Wheelchair
3 How far can you walk before limited by pain: Unlimited Indoor only Less than 2 blocks 2-10 blocks More than 10 blocks (30 minutes) Unable to walk Difficulty with stairs: None Normal going up, difficult going down One at a time Need to hold banister Unable to walk up stairs Can you sit comfortably: Unlimited Less than 1 hour Severe discomfort Discomfort arising from chair Have you seen anyone for this problem Yes No If yes, who: Family doctor Orthopaedic Surgeon Therapist Other: Name, Location, Phone Type of Treatment Did your symptoms improve after: Yes No Please describe: Please describe your hobbies/ activities: REVIEW OF SYSTEMS HEENT (Head, Ears, Eyes, Nose, and Throat): Normal Headaches Glaucoma Cataracts Dental Problems Sinusitis PULMONARY (Lungs): Normal Asthma COPD Shortness of Breath CARDIOVASCULAR (Heart): Normal Chest Pain Palpitations Previous Heart Surgery Abnormal rhythm NEUROLOGIC: Normal Stroke Seizure Headaches Motor/Sensory Deficit GASTROINTESTINAL: Normal Stomach pain with NSAIDs (Motrin, Ibuprofen) Ulcer Heartburn GI/Rectal Bleed Adverse reaction to NSAIDs: GENITOURINARY: Normal Frequent night-time urination Prostate Incontinence Burning with urination SKIN: Normal Skin rash Psoriasis
4 MUSCULOSKELETAL Normal except shoulder Other joint pains: location PAST MEDICAL HISTORY Please list any Medical Illnesses (i.e. diabetes, high blood pressure, etc ) List any prior surgeries Type of Surgery Year Hospital Surgeon List any allergies to medications Medication Side Effect List current medications being taken on a regular basis (include dose and how often) FAMILY HISTORY Father Living Any medical problems: Deceased at age Cause: Mother Living Any medical problems: Deceased at age Cause: Siblings: Number Any medical problems: SOCIAL HISTORY Marital Status: Married Single Divorced Number of children: Do you smoke? No Yes If so how many packs per day: Do you drink alcohol? No Occasionally Daily Employment Type of work:
5 Currently working: Yes No If not working: Are you temporarily unemployed off work how long Any heavy lifting involved with work: Yes No To the best of my knowledge, the questions on this form have been answered accurately. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor of any changes in my medical status. I also authorize the health care staff to perform the necessary services I may need. Signature of Patient or Parent of Minor Date
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WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
Potomac Valley Chiropractic Personal Injury
Potomac Valley Chiropractic Personal Injury Spiro Theodore, D.C. 12105 Darnestown Road, L8 Gaithersburg MD 20878 Please Complete all applicable fields Date: -------------------------------------------------------DEMOGRAPHICS--------------------------------------------------------------
Upper Arm. Shoulder Blades R L B R L B WHICH SIDE IS MORE PAINFUL? (CERVICAL PAIN SIDE) RIGHT LEFT EQUAL NOT APPLICABLE (N/A) CERVICAL.
1 NECK PAIN Patient Name In order to properly assess your condition, we must understand how much your NECK/ARM problems has affected your ability to manage everyday activities. For each item below, please
PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT
Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, 72034 501.329.1510 Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex:
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medicare Insurance Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
1. NAME 2. SOCIAL SECURITY NUMBER # 4. PRESENT OCCUPATION 5. PLANT 6. ADDRESS 8. TELEPHONE NUMBER 9. INTERVIEWER
ASBESTOS INITIAL MEDICAL QUESTIONNAIRE 1. NAME 2. SOCIAL SECURITY NUMBER # 3. CLOCK NUMBER 4. PRESENT OCCUPATION 5. PLANT 6. ADDRESS 7. (Zip Code) 8. TELEPHONE NUMBER 9. INTERVIEWER 10. DATE 11. Date of