TODAY’S DATE:_________ PATIENT NAME: _____________________DATE OF BIRTH: _______________ AGE: _____ HOME PHONE #: _______________ CELL PHONE #:_____________ 1). Please explain what your problem is and what your goals and expectations are: 2). Are you interested in a surgical procedure or non-surgical procedure? 3). If you are here for knee pain check where you have pain: ___medial (big toe side), ___lateral (little toe side), ___anterior compartment (knee cap), ____generalized. 4). If you are here for hip pain check where you have pain: ___groin,___ outer hip area, ___buttock ,___anterior thigh, ___ knee ,___ anterior leg 5). How long have you had pain? ___________ 6). How many blocks can you walk comfortably? ___Less than 1 block, ___1-2 blocks, ___3-6 blocks, ____Over 6 blocks 7). Please mark the activities that bother you: ___walking, ___getting out of a chair, ____doing stairs,___trouble sleeping,___trouble getting dressed 8). Do you have: ___swelling, ___stiffness, ___joint locks, __giving out, ___don’t trust your extremity to hold you, ___trouble getting dressed, __trouble sleeping 9). Do you use a cane? ____ Do you use a walker? ____ 10). Are you on any blood thinners? Such as: Plavix, Coumadin, Xarelto, Pradaxa, Pletal, or Aggrenox. 11). Are you on any rheumatoid drugs? Such as: Methotrexate, Humira, Remicade, or 12). Are you on anything for pain? ________________________________________ 13). If you have cortisone when was your last injection? _________________________ 14). If you have had visco supplementation (“chicken shots”) when was your last shot____ 15). List any surgery on your hip or knee. Date of surgery and where surgery was performed. ______________________________________________________________ GENERAL MEDICAL QUESTIONS 1). Have you seen your dentist in the last six months? YES - NO 2). Circle any of the following risk factors you might have for your heart: Angina – requiring taking nitroglycerin Vascular Disease – such as stroke Heart Attack Hypertension Diabetes High Cholesterol Smoking Positive Family History of Heart Attack (mother, father, or siblings) Obesity Sedentary Activity (Walking less than 1-2 blocks at a time) 3). Do you have a history of a cardiac bypass, coronary angioplasty? __________ 4). Do you have a history of a pulmonary embolism, (blood clot in your lung), DVT, (phlebitis in your leg)______ 5). Have you ever had a bleeding ulcer? YES - NO 6). Do you have a history of sleep apnea? YES - NO If so, mark risk factors you may have: ___Snoring, ___obesity, ___ hypertension, ___excessive tiredness during the day, ____getting up at night, ____ observed apneas, ___congestive heart failure, ____coronary artery disease, ____atrial fibrillation, ___ 17” neck male,___16” neck female
Weils Disease I Leptospirosis Leptospirosis is a disease that can be passed from animals to humans. Leptospirosis is caused by bacteria of the genus Leptospira, (referred to as Leptospires) which infect a variety of wild and domestic animals. The animals can then spread the Leptospires in their urine. Common animal reservoirs (maintenance hosts) include rodents, cattle and pigs. Human i
