Patient Medical Questionnaire Form

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Dictated? _________
[LABEL]
Patient Questionnaire
Please complete the first two pages completely
Appt. Date:_____________
Age: _____
Are you Right or Left Handed? R / L Which side is involved? R / L
If a minor, please provide name of parent or guardian ______________________________________________
How do you prefer to be addressed? (circle one)
Mr.
Mrs. Ms.
Dr. Other ______________________
Married? (circle one)
Y
N
Who requested us to see you? ________________________________________________
Physician’s Street Address: __________________________________________
Physician’s Town/City, State/Zip: _____________________________________
Physician’s office phone #:____________________________________________
Is this your Primary Care Provider? Y / N
If not, please provide Name: _____________________________________________________
Address: ___________________________________________________
Occupation: __________________________________________________________________________________
Are you currently working? Y / N (circle one)
Why are we seeing you today? ___________________________________________________________________
Rate the severity of your symptoms: (0 =none 1 2 3 4 5 6 7 8 9 10= worst possible)
When are your symptoms the worst? (circle):
Night
Day
Neither
How long have you had these symptoms?__________________________________________________________
Is this problem the result of an injury? (circle one)
Y / N If yes, Date of Injury ______________________
Have you been treated for this problem before? Y / N (circle one)
Were you injured at work? Y / N (circle one)
Will this be filed as Workers’ Compensation? Y / N (circle one)
Have you or a member of your family ever been treated by Lexington Clinic Orthopedics, Sports Medicine or
Hand Surgery? Patient’ name _________________________
by Doctor _____________________________
Have you ever had Surgery? Y / N (circle one) If so, please list below:
Type of surgery
Date
Type of surgery
Date
(Please complete the reverse side)

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