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

Ortho Questionnnare Medical Form

Orthopedic Surgeon

There are 25 copies in use.
Published: Feb. 2, 2015, 11:57 a.m.
Doctor: Dr. History Physical
Rating: +5   /

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Sunnyvale, CA 94089

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