Firststateortho.com

INTAKE FORM
□Dr.Axe □Dr.Bodenstab □Dr.Brady □Dr.Crain □Dr.Ginsberg □Dr.Handling □Dr.Hershey □Dr.Johnson □Dr.Kahlon □Dr.Katz
□Dr.Leitman □Dr.Moran □ Dr. Newell □Dr.Pushkarewicz □Dr.Raisis □Dr.Rudin □Dr.Sowa □Dr.Steele □Dr.Straight □Dr. Zaslavsky
PATIENT INFORMATION
Date: __________ Name: ______________________________________ Age: ________ FSO MR #: ________________
REASON FOR VISIT - Ort Home
Body Part(s): ___________________________________________________________________________________ □ Right □ Left □ Bilateral
Complaint: □ Pain □ Injury □ Fracture □ Numbness □ Swelling □ Other: _____________________________________________________________
HISTORY OF PRESENT INJURY - HPI: This Chief Complaint
Have you been off work for this problem?: □ Yes □ No Dates off work: __________________________________________________________________
Doctors who have treated you for this problem: __________________________________ Did that doctor refer you here?: □ Yes □ No
Diagnostic tests and treatment performed (please list when/where/what) : □ X-Ray _______________________ □ MRI ________________________________
□ Injection _________________ □ Surgery: _________________ □ NSAIDS (anti-inflammatories) _________________ □ EMG _______________________ □ CT/Scan _______________ □ Bone Scan _______________ □ Lab Work _______________ □ Other: _______________ □ PT ______________________ Have you ever had similar problems? If yes, please give details: __________________________________________________________________________
Onset/Date of Injury: __________________
Context: □ No Injury □ Injury □ Sports Injury □ MVA - Details:____________________________________
Severity:
Frequency:
Quality:
Radiation:
Radiates To: _______________
Aggravated By:
Relieved By:
Associated Symptoms / Pertinent Negatives:
Hand Dominance:
REVIEW OF SYSTEMS - Add Additional ROS
Do you have any of the following symptoms? (Please check all that apply) Constitutional:
Metabolic/Endocrine:
Neurological:
Immunological:
Hematologic/Blood:
Cardiovascular:
Respitory:
□ Cyanosis (blue coloration of skin) Gastrointestinal:
Integumetary/Skin:
Genitourinary:
PATIENT'S MEDICAL CONDITION - Assistant Doc>Vital Signs
Height: ___ft ___in Weight: _____lbs Blood Pressure:_____/_____ List details of any diet program: ____________________________
My weight in the last 6 months has: □ Not Changed □ Increased _____lbs. □ Decreased _____lbs.
Have you ever taken any anti-inflammatories/arthritis medications?: □Yes □No (Ex: Naprosyn/Ibuprofen) If yes, please list: _______________________
ALLERGIES - Assistant Doc>Add Allergy
(Please check all in which you have an allergy and list the reaction - hives, nausea, anaphylaxis, etc) Reaction:
Reaction:
Allergy & Reaction:
(anti-inflammatories - ibuprofen, naprosyn) □ No Known Drug Allergies
PATIENT'S MEDICAL HISTORY - Histories>Additional History
□ Degenerative Joint Disease □ Inflammatory Bowel Disease □ Juvenile Rheumatoid Arthritis □ Renal Disease PATIENT'S SURGICAL HISTORY - Histories>Additional History
□ Small Bowel Resection ______________________ Gender Specific
_________________________ (gallbladder removal) □ Neck Surgery - Details: □ Cesarean Section PATIENT'S FAMILY HISTORY - Histories> Additional Family History
Is your Father Living? □ Yes □ No If no, age deceased ________ cause of death ______________________________
Is your Mother Living? □ Yes □ No If no, age deceased ________ cause of death _______________________________
Are any of your brothers/sisters deceased? □ Yes □ No If yes, age deceased _______ cause of death ______________________________
Family history of chronic/inherited diseases: ________________________________________________________________________________
PATIENT'S SOCIAL HISTORY - Histories>Social History
Tobacco Use: □ Yes □ No □ Former/Year Quit _______
Consume Alcohol: □ Yes □ No □ Former/Year Quit _______
Activity Level: □ Sedentary □ Moderate □ Vigorous
Type of Exercise: _________________________ _______________________
SIGNATURE
Date: __________________ Signature of Patient, Parent or Guardian: ______________________________________________________________

Source: http://www.firststateortho.com/pdf/FSO-Patient-History-Form.pdf