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1 Lloyd C. Briggs, Jr., M.D., M.S. Board Certified, American Board of Orthopaedic Surgery Fellowship Trained in Foot and Ankle Surgery Fellow American Academy of Orthopaedic Surgery Member American Orthopaedic Foot and Ankle Society Greetings, In the near future, you are scheduled to meet with Dr. Briggs at the Orthopaedic Institute of Ohio. Dr. Briggs is a foot and ankle fellowship trained orthopaedic surgeon who specializes in foot and ankle surgery. He and our staff are dedicated to try to help people with both major and minor foot and ankle problems. In preparation for your visit, we have three recommendations. First, in order to make your visit as productive as possible, we ask that you take the time to fill out the enclosed questionnaire which asks you to describe your medical problem and give a detailed past medical history. The foot and ankle is an integral part of your body and it is affected by other medical problems you may have. It is important that we have as much information as possible concerning your medical health in order to properly diagnose your problem and provide a treatment plan that is best suited for you. Your own description of your injury or problem is often times the most important factor in making a proper diagnosis, as well as, understanding how this problem affects your life. We realize no one likes to fill out paperwork, but please take the time to fill out the form in its entirety before your visit. This will help us be as thorough as possible and will ultimately benefit you. Second, written reports of x-rays, MRIs, CT scans, and bone scans can be inaccurate. In order to be as thorough as possible, we like to review the original films of any x-rays, CT scans, MRI scans, or bone scans you might have undergone. Sometimes the reports are helpful and sometimes they are not. Reading the actual films gives us far more information than the reports typically do. From past experience, if you call your doctor s office or the hospital, and ask them to send films or medical records, 75% of the time we do not end up getting them in time for your visit. To ensure that these records or films are present for your visit, please pick up the records and film yourself to be sure we have them for your visit. Do not rely on the mail or courier service to get the films to the office in time for the appointment. Third, for the physical exam, we usually like to examine the foot, the ankle and legs up to, and above the knees so please bring a pair of shorts or wear a pair of pants which can be easily rolled up above the knees. In addition, for your initial visit, please bring the shoes you wear most often as well as any braces, orthoses, or shoe inserts you use or have used. Finally, thanks for your time and cooperation. We look forward to trying to help you with your problem. If you have any problems please feel free to call and speak with Michelle at (ext. 3391) and she will try to help you. REMEMBER TO BRING YOUR COMPLETED FORM WITH YOU TO YOUR VISIT. If you forget, we can give you another one at the time of your visit, but you will have to fill it out before you can be seen. Thanks again, Lloyd C. Briggs, Jr., M.D., M.S. and the staff at the Orthopaedic Institute of Ohio «FirstName» «LastName»
2 Orthopaedic Institute of Ohio 801 Medical Drive, Suite A Lima, Ohio (419) Dear New Patient, Recently, you have been scheduled for a surgical consultation with Dr. Briggs at the Orthopaedic Institute of Ohio. We would like to welcome you to our practice and assure you that we will do everything we can to help you with your current foot or ankle problem. In order to make your visit as productive for you as possible we would like to make you aware of Dr. Briggs office policies. Dr. Briggs is a Board Certified Orthopaedic surgeon who completed a Foot and Ankle fellowship in New York City before coming to Lima. While we certainly help many people with therapy or bracing, the primary emphasis of his practice is on the surgical treatment of foot and ankle problems. Often times our ability to help you will depend on whether or not your problem can be treated with surgery. If for some reason you cannot have surgery or your problem cannot be fixed with surgery, we may not be able to help you very much with your problem. We also need to let you know that because his practice is primarily surgical, Dr. Briggs does not prescribe narcotics for the treatment of pain, with the exception of the first couple weeks after surgery or the first couple of weeks after a fracture. Treatment of pain with medications for longer than a few weeks is referred to as chronic pain management. This is not something Dr. Briggs does. If you are on narcotics or other types of pain medications now, you should continue to get them from the physician who prescribed them to you because Dr. Briggs will not write for, or continue those medications. If you think that pain medications should be part of your long term treatment, Dr. Briggs recommends that you seek a health care provider who provide chronic pain management, (long term, medication-oriented pain management) so you can be safely monitored long-term with these medications. Finally, we need to let you know that Dr. Briggs does not perform permanent disability evaluations. The emphasis of our practice is to return people to work as soon as possible. Unfortunately, there are some people whose injury or injuries are so severe that they cannot return to work and they are best off seeking permanent disability. Unfortunately, our practice does not provide that service at this time. So if the purpose of your visit is to seek permanent disability, you should make other arrangements. If you have any questions concerning these policies or other questions about the practice please feel free to call Michelle, my assistant, at , ext Sincerely, Dr. Briggs Staff at the Orthopaedic Institute of Ohio.
3 Lloyd C. Briggs, Jr., M.D., M.S. Orthopaedic Surgery Patient I nfor mation Foot & Ankle Surgery Please darken bubbles completely and PLEASE PRINT CLEARLY Patient Name: A ppointment Date: DOB: A ge: H eight: W eight: BP: Male Female R efer r ing Doctor : F amily Doctor : Occupation: How would you characterize your job (choose one): Mostly sit down work Manual labor Combination of both Does your job have specific shoe wear requirements? Yes No Are you a Health Care worker? Yes No What foot or ankle concerns would you like addressed by your doctor today? Left Right or Both What bothers you most about your foot or ankle? Pain Swelling Feels unstable Deformity Stiffness When did your condition begin? Was it related to an injury? Yes No If so, describe the injury? Did the problem develop suddenly or gradually (choose one)? Gradually Suddenly What is the quality of your pain (choose all that apply)? Sharp Stabbing Aching Pins and Needles Burning What qualities describe your pain (choose all that apply)? Shoots up or down the leg Is better with shoes on No difference between wearing and not wearing shoes Hurts just as much in the morning as it does later in the day Wakes me up at night Is better without shoes Worse with activity Gets worse as the day goes on You are always aware of the pain Which activities make your symptoms worse? Standing Walking Walking on uneven ground Wearing certain types of shoes Running Going up stairs Going down stairs Getting up from a seated position Stabbing Aching Pins and Needles Burning Mark the scale with a vertical line to indicate your average pain during the day due to your foot and ankle condition: No Pain Worst Pain Imaginable
4 What things are you unable to do or are severely limited because of the pain/ problem (choose all that apply)? Sleep Take care of yourself Get around your home Enjoy life Run Walk even limited distances Exercise Play sports Enjoy life Engage in hobbies Work and perform at work Walk to exercise Which of the following treatments have you tried? Anti-inflammatory medications (which kind and how long)?: Activity modifications Icing Compression wrapping Stretching exercises Physical Therapy Braces Chiropractic care Massage therapy Shoe inserts Heel lifts Prescription orthotics Over-the-counter orthotics Taping Cast Injections Shoe modifications Walker boot Night splint Shoe modifications Surgery L ist any diagnostic studies (M R I, CT, B one Scan, V ascular Studies, EMG) you ve had for this condition along with a date and location of wher e the study was performed: Allergies: Allergies to metals: Yes No Allergies to latex: Yes No Allergies to foods: Yes No Allergies to medications : Yes No Please list (medication and reaction): L ist all your current medications: Personal Medical History (Please circle all that apply): Anemia Gout Osteoporosis High Blood Pressure Cancer Mental Illness Seizures Phlebitis Chronic Back Pain Sciatica Alcoholism AIDS Fibromyalgia Irregular Heart Beat Leg Stents Depression Diabetes Stroke Bleeding/Bruising tendency Heart Stents Heart Condition Heart Attack Blood Clots Kidney Transplant or Dialysis Stomach Ulcers Osteo Arthritis Sleep Apnea Pulmonary Embolism (blood clot in lung) Metal Allergies Rheumatoid Arthritis Pacemaker Asthma/Emphysema/Wheezing Defibrillator Malignant Hypothermia Cochlear Implants
5 L ist any sur gical pr ocedur es by year, star ting with the most r ecent: Review of Systems (Please cir cle all that apply, r ecent or current only): Fever Fatigue Weight Loss Headache Loss of Appetite Trouble Swallowing Nausea/Vomiting Constipation Diarrhea Muscle Cramps Joint Stiffness Joint Swelling Joint Weakness Muscle Weakness Swelling of Feet Memory Loss Balance Problems Coordination Problems Tremors Dizziness Fainting Cold Hands or Feet If any apply, please explain: Have you been seen by a Dentist in the last year? No Yes Do you have any dental problems (broken, chipped or loose teeth, abscess, gum disease)? No Yes If yes, please explain: Social History Do you participate in any Sports or regular exercise activity: No Yes If yes, what type? What activities do you enjoy during your free time? Do you smoke? No Yes How much? Do you drink alcohol? No Occasional Several times a week Daily Where do you reside? Home Nursing Home Assisted Living Other: Do you currently see anyone for Pain Management? No Yes Provider: In the past, have you seen anyone for Pain Management? No Yes Provider: Family History Please circle any relevant medical conditions that run in your family (Mother, Father, Siblings, Grandparents): Osteo (old age) arthritis: M F S G Rheumatoid arthritis: M F S G Gout: M F S G Lupus: M F S G History of problems with anesthesia: M F S G Malignant Hypothermia: M F S G Diabetes: M F S G Other, relevant conditions (please specify): Pr int Patient Name: DOB : Patient Signatur e: Date:
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