ORTHOPEDIC HISTORY Name: _________________________________________ Today’s Date: ________________

Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs

Primary Doctor Name and Address: Referring Doctor Name and Address:

______________________________________ ______________________________________

______________________________________ ______________________________________

If not referred, how did you choose this office? ____________________________________________

Why are you seeing the doctor today? (body part) __________________________________________

How long has the pain/problem been present? _____________________________________________

Has the pain/problem worsened recently? No Yes, how recently?________________________

What started the pain/problem? ________________________________________________________

Quality of the pain: Sharp Burning Dull Aching

How severe is the pain at the location described above?

No Pain Mild Moderate Severe

What makes the pain/problem better? ___________________________________________________

What makes the pain/problem worse? ___________________________________________________

Is the pain (check all that apply): Continuous Activity Related Night Pain Unpredictable

Did this problem start at work? ________________________________________________________

Have you already filed or will you file a Workers’ Compensation claim? _______________________

Have you missed work because of this problem? __________________________________________

What ever treatments have you tried?

Physical Therapy/Exercise TENS unit Narcotic medications Cass/boot

Massage/Ultrasound Traction Anti-Inflammatories Orthotics

Manipulation Surgery Steroid injections Braces

Are you right hand ___ or left ___?

Previous physicians seen for this problem Physician Specialty City Treatment

ORTHOPEDIC HISTORY Medications take for this problem

Name of Medication Dose Reason

X-Rays and Tests for this problem:

Results Date Location

X-Rays

MRI

CT Scan

Bone Scan

Other

Because of this problem, have you filed or do you plan to file a lawsuit? Yes No

If you are a new patient to our practice, please complete the Comprehensive Health History. If you

have previously completed a Comprehensive Health History during a visit to our practice, have there

been any changes to your medical history, surgical history or medications since that time? Please

describe any changes below:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Responsible party’s signature :____________________________________

FOR OFFICE USE ONLY I have read and confirmed the above information with the patient. X __________________________________________________

Alton Orthopedic Clinic

John Stirnaman MD - Board Certified Orthopedic Surgeon

Michael Taylor MD - Board Certified Orthopedic Surgeon

Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine

Lesley M. Davila, MD - Rheumatologist

Donald LeMoine PA-C

#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002

COMPREHENSIVE HEALTH HISTORY Name: _________________________________________ Today’s Date: ________________

Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs

Primary Doctor Name and Address: Preferred Pharmacy (Address/Phone)

______________________________________ ______________________________________

______________________________________ ______________________________________

PAST MEDICAL HISTORY: Check all that apply None Apply

Heart attack Asthma Rheumatoid arthritis Depression

Heart failure Tuberculosis Osteoarthritis ADHD

Abnormal heartbeat Emphysema Gout Seizures

High blood pressure Thyroid Osteoporosis Migraine

Stroke Stomach ulcers Cirrhosis Cerebral palsy

Blood clots in leg Gastric reflux Hepatitis (A, B or C) Downs syndrome

Blood clots in lung Hiatal hernia HIV/AIDS Spina bifida

Poor circulation Kidney failure Bleeding disorder Neurofibromatosis

High cholesterol Kidney stones Anemia

Neuropathy: Hands or Feet

Cancer: _________________________________________________________(type/treatment)

Diabetes: year diagnosed __________

Currently controlled with insulin oral medications diet Other: __________________________________________________________________________

__________________________________________________________________________________ PAST SURGICAL HISTORY: No Prior Surgery

latipsoH/noegruS etaD noitarepO

Have you every had general anesthesia? No Yes If yes, have you had any problems related to this? No Yes Please explain any problems related to general anesthesia: ___________________________________ __________________________________________________________________________________

Alton Orthopedic Clinic

John Stirnaman MD - Board Certified Orthopedic Surgeon

Michael Taylor MD - Board Certified Orthopedic Surgeon

Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine

Lesley M. Davila, MD - Rheumatologist

Donald LeMoine PA-C

#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002

COMPREHENSIVE HEALTH HISTORY MEDICATIONS (prescribed and over the counter): I take no medications

METAL ALLERGIES: No Allergies YES_______________________________(List Metals)

SOCIAL HISTORY:

Work status

Working Homemaker Unemployed Disables On Leave Retired Student

Occupation_________________________________________________________________________

Marital Status: Single Married Divorced Widowed

Children No Yes, How many? ______

Do you live alone? ______ If no, who lives with you? ______________________________________

Are you currently smoking?_____ If yes, how many packs a day?___ For how many years?_______

How many packs a day did you previously smoke? ___ Other forms of tobacco? ________________

Alcohol Use Never Rare Social Frequently (more than twice a week) Alcoholic Recovering Alcoholic Illegal Drug Use Never In the past Currently Types of Drugs_____________________

Name of Medication Dose Reason

ALLERGIES TO MEDICATIONS: No Allergies

Name of Medication Reaction (rash, swelling, stomach upset, etc.)

Alton Orthopedic Clinic

John Stirnaman MD - Board Certified Orthopedic Surgeon

Michael Taylor MD - Board Certified Orthopedic Surgeon

Aaron P. Omotola, M.D. - Fellowship Trained in Orthopaedic Sports Medicine

Lesley M. Davila, MD - Rheumatologist

Donald LeMoine PA-C

#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002

COMPREHENSIVE HEALTH HISTORY FAMILY HISTORY: Check all that apply None Apply

Heart problems Diabetes Arthritis Bleeding problems

Seizure Cancer High Blood Pressure Stroke

Gout Kidney problems Lung problems Mental Illness

msilohoclA Blood clots (legs or lungs

Other: _____________________________________________________________________________

REVIEW OF SYSTEMS: (In the past 30 days have you experienced any of the following?)

Fever Sleep apnea (snoring) Nausea

Chills Hoarseness Vomiting

Weight loss Cough Diarrhea

Vision changes Trouble swallowing Constipation

Vision changes Chest pain Hemorrhoids

Glasses/Contacts Palpitations Stomach pain

Hearing loss Swollen ankles Urinary difficulty

Dizziness Shortness of breath Anxiety

Ear pain Seasonal allergies Hyperactivity

Nosebleeds Skin rashes Memory loss

Toothache Swollen glands Blackouts

Gum problems Poor appetite Headache

I have not experienced any of the above symptoms in the last 30 days

Other: __________________________________________________________________________

__________________________________________________________________________________

FOR OFFICE USE ONLY I have read and confirmed the above information with the patient/family: Physician Signature:_______________________________________ Date:_______________________