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Knee History
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CHIEF COMPLAINT
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Is today's condition a result of an accident?
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If yes, Please circle
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If other accident, please specify
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Which knee
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HISTORY OF PRESENT ILLNESS:
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Describe your Symptoms?
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How severe it is?
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How long have you had it?
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What aggravates the pain?
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Other
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Any mechanical symptoms?
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How far can you walk before having knee pain?
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Is the knee Stiff?
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Do you have night Pain?
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Do you wok out with weights?
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Any Swelling?
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Any history of trauma?
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If yes, When and how?
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Any previous Knee surgery?
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If yes, when and what kind?
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Prior Injections?
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Any pain in the Hip or groin?
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Any of the following decrease the pain
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Rest
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Ice:
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Heat
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Over the counter Meds
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Prescription meds
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Anything else that decreases your pain?
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Any previous X-rays or MRl's?
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Seen any other doctor for this problem?
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If yes, who and when?
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Ever had knee problem before?
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If yes, Explain
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Fallen due to knee condition
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Daily activity/ Work activity
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Other
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What is your job description?
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Do you have a good appetite?
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Had unexpected weight loss?
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Hip History
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CHIEF COMPLAINT
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Is today's condition a result of an accident?
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If yes, Please circle
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Which Hip?
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HISTORY OF PRESENT ILLNESS:
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Where is your pain?
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How severe is it?
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New Field
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How long have you had it?
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Describe the pain
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What aggravates the pain?
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Other
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How far can you walk before having hip pain?
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Do you have night Pain?
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Do you have Back Pain?
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Does it travel down your leg?
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Do you have numbness or tingling?
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Do you limp?
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Resorted to a cane, walker or wheelchair?
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Have you fallen due to a hip condition?
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Any history of trauma or injury?
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If yes, when and how?
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Previous surgeries to the hip?
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If yes, When and What Kind?
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Prior Injections?
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Any of the following decrease the pain
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Rest
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Ice:
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Heat
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Over the counter Meds
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Prescription meds
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Anything else that decreases your pain?
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Any previous X-rays or MRl's?
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Seen any other doctor for this problem?
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If yes, who and when?
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Had this problem before on the other side?
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If yes, Explain
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Daily activity/ Work activity
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What is your job description?
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Do you have a good appetite?
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Had unexpected weight loss?
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Shoulder Pain
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Which shoulder is bothering you?
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Are you?
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What type of work do you do?
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Shoulder pain start with a specific injury?
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If yes, Date of Injury
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Mechanism of Injury
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Did you feel a pop or snap with the Injury?
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Is the injury work related?
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Is it result of car accident?
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If no injury, did pain start with a activity?
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If yes, What started the pain?
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If no Injury, when did the pain start?
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Primary sports and/or activities
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How do you describe your pain?
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How severe it is?
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Dropped items due to shoulder conditions?
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Any of the following increase the pain
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Sleeping on the affected shoulder:
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Lifting your arms overhead
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Reaching out from your side
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Reaching behind your back
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Throwing Motion
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Participating in sports
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Participating in sports
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Work Activities
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Anything else that increases your pain?
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Any of the following decrease the pain
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Rest
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Ice:
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Heat
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Over the counter Meds
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Prescription meds
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Anything else that decreases your pain?
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Pain move down your arm or up into your neck
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Do you have shoulder pain at night?
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Have any of the following symptoms
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Other symptoms regarding your shoulder?
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Had previous surgery to your shoulder?
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If yes, what type and when
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Previous Treatment for shoulder pain such as
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Other Previous treatment for shoulder Pain
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In General are your symptoms getting
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Had any X-rays taken of your shoulder?
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If Yes, Date
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X-ray facility
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Had an MRI for your shoulder?
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If Yes, Date
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MRI facility
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HEALTH MAINTENANCE:
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Had a Bone Mineral Density Scan (Dexa scan}?
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Month/Year of last Dexa
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PAST MEDICAL HISTORY
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Other
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SURGICAL HISTORY
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Ankle/Foot Surgery
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If yes, Year
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Comments
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Please Seelect
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Abdominal Surgery
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If yes, Year
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Comments
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Appendectomy (appendix removal)
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If yes, Year
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Comments
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Back Surgery (lumbar)
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If yes, Year
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Comments
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Bowel or Bladder Surgery
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If yes, Year
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Comments
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Biopsy (location)
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If yes, Year
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Comments
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Please Seelect
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Breast Surgery
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If yes, Year
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Comments
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Please Seelect
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Colonoscopy
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If yes, Year
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Comments
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Coronary Bypass
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If yes, Year
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Comments
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Coronary Stent
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If yes, Year
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Comments
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EGD (Stomach Endoscopy)
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If yes, Year
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Comments
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Cataract
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If yes, Year
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Comments
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Gallbladder Removal
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If yes, Year
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Comments
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Heart Surgery ( other than coronary bypass)
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If yes, Year
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Comments
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Hip Surgery
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If yes, Year
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Comments
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Please Seelect
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Hysterectomy (total, including ovaries)
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If yes, Year
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Comments
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Hysterectomy (partial, ovaries left)
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If yes, Year
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Comments
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Please Seelect
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Knee Surgery
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If yes, Year
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Comments
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Please Seelect
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LEEP (Cervix surgery)
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If yes, Year
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Comments
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Lung Surgery
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If yes, Year
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Comments
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Neck Surgery
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If yes, Year
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Comments
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Ovary ligation (tubal)
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If yes, Year
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Comments
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Ovary Removal
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If yes, Year
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Comments
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Pacemaker
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If yes, Year
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Comments
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Please Select
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Vasectomy
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If yes, Year
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Comments
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Shoulder Surgery
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If yes, Year
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Comments
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Please Seelect
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Sigmoidscopy
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If yes, Year
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Comments
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Sinus Surgery
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If yes, Year
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Comments
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Surgery for fracture
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If yes, Year
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Comments
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Please select
• • •
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Wrist/Hand surgery
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If yes, Year
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Comments
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Please Seelect
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Total Hip Surgery
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If yes, Year
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Comments
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Please Seelect
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TotaI Knee Surgery
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If yes, Year
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Comments
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Please Seelect
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FAMILY HISTORY
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Mom
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Other
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Dad
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Other
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Sister
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Other
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Brother
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Other
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Daughter
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Other
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Son
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Other
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SOCIAL HISTORY:
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Patient smokes Cigarettes?
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If quit, Date
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If smoking, Packs per day
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# of yrs
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Other Tobacco
• • •
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Do you drink alcohol?
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#drinks/week
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Do you use recreational drugs?
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Have you ever used needles?
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Do you exercise daily?
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What kind of exercise?
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OCCUPATION
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Type of work/job requirements:
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Other
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