Orthopedic Surgery New Patient Self Assessment Form
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PATIENT IDENTIFICATION AREA
PATIENT IDENTIFICATION AREA
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Orthopedic Surgery
Orthopedic Surgery
New Patient Self Assessment Form
New Patient Self Assessment Form
Page 4 of 4
Page 1 of 4
REVIEW OF SYSTEMS
TELL US ABOUT YOURSELF
Are you currently, or have you ever had problems with:
Patient Name: _______________________________________
Date of Birth: ________________________________________
HOW YOU FEEL
CIRCLE ONE
YOUR MUSCLES & BONES
CIRCLE ONE
Fever
Yes
No
Broken Bones
Yes
No
Phone:______________________________________________
Best time to call: _____________________________________
Unexpected Weight Loss
Yes
No
List:_____________________________
Excessive Fatigue
Yes
No
Arm or Leg Weakness
Yes
No
PRIMARY CARE MD: ________________________________
REFERRING MD: ____________________________________
Night Sweats
Yes
No
Back Pain
Yes
No
Loss of appetite
Yes
No
Arm or Leg Pain
Yes
No
Address:
_________________________________________
Address:
_________________________________________
YOUR EYES
Joint Pain or Swelling / Arthritis
Yes
No
Wear Glasses or Contacts
Yes
No
Numbness
Yes
No
_________________________________________
_________________________________________
Infections
Yes
No
Osteoporosis
Yes
No
Phone:
_________________________________________
Phone:
_________________________________________
Injuries
Yes
No
Instability / giving way / dislocation
Yes
No
YOUR EAR, NOSE, THROAT & MOUTH
Stiffness
Yes
No
PRESENT HISTORY
Wear Hearing Aids?
Yes
No
Scoliosis
Yes
No
Date of last Exam:________________
Spinal Conditions
Yes
No
Reason for today’s visit (chief complaint): ______________________________________________________________________
Hearing Loss
Yes
No
YOUR SKIN
Ear Infections
Yes
No
Skin Cancer
Yes
No
How long have you had this problem? _________________________________________________________________________
Balance Disturbance
Yes
No
Skin Ulcers
Yes
No
Sinus Problems
Yes
No
YOUR BRAIN & NERVES
Do you have any pain as a result of this problem? Ë Yes Ë No
YOUR HEART
Fainting Spells or “Blacking Out”
Yes
No
Chest Pain or Angina
Yes
No
Seizures
Yes
No
If yes, on a scale of 1-10, 10 being the greatest, how would you describe this pain? ________
Date of Last EKG:________________
Coordination in Arm and / or Legs
Yes
No
High Blood Pressure
Yes
No
Stroke
Yes
No
How would you describe your pain? (e.g. sharp, dull, aching, burning, shooting)____________________________________
Irregular Pulse
Yes
No
Balance Problem
Yes
No
Heart Murmur
Yes
No
Headaches
Yes
No
What about its frequency? (please circle all that apply) daily / nightly / constant / intermittent
Heart Attack
Yes
No
YOUR GLANDS
Blood Clots
Yes
No
Diabetes
Yes
No
What makes your problem better / worse? ______________________________________________________________________
YOUR LUNGS
Treatment________________________
(lying, bending, sneezing, standing, lifting, walking, sitting, coughing) or (rest, exercise, sitting, lying down, other)
Asthma
Yes
No
Thyroid Disease / Disorder
Yes
No
Chronic Cough
Yes
No
Hormone Problems
Yes
No
Current Limitations: __________________________________________________________________________________________
Emphysema
Yes
No
YOUR BLOOD
Current problem is the result of a(n): Ë Car Accident Ë Work Accident Ë Accident Ë Other (Check all that apply)
Shortness of Breath
Yes
No
Anemia
Yes
No
Bronchitis
Yes
No
Hemophilia
Yes
No
Date of Injury: _______________________________________________________________________________________________
Pneumonia
Yes
No
Bleeding Tendencies
Yes
No
Lung Cancer
Yes
No
Persistent Swollen Glands/Lymph Nodes Yes
No
Previous treatments other than surgery: ________________________________________________________________________
Tuberculosis
Yes
No
Blood Transfusion
Yes
No
Sleep Apnea
Yes
No
If yes, when?_____________________
Previous surgery for this problem: _____________________________________________________________________________
YOUR STOMACH & INTESTINES
Easy bleeding
Yes
No
Nausea
Yes
No
Easy bruising
Yes
No
PAST HISTORY
Vomiting
Yes
No
Cancer
Yes
No
Ulcers or Gastritis
Yes
No
YOUR ALLERGIES & IMMUNE SYSTEM
Please list any prior illnesses and /or injuries:
Colon Cancer
Yes
No
Inhalant (Nasal) Allergies
Yes
No
Stomach Ulcer
Yes
No
Immunologic Disorders
Yes
No
____________________________________________________________________________________________________________
Hepatitis
Yes
No
YOUR FEELINGS
YOUR KIDNEYS & URINE
Anxiety
Yes
No
____________________________________________________________________________________________________________
Urinary Tract Infections
Yes
No
Depression
Yes
No
Kidney Stones
Yes
No
Other Psychiatric Disorder
Yes
No
Are you under the care of a Cardiologist: Ë Yes Ë No
Name:_________________________________________________
Kidney Disease
Yes
No
Treatment:_______________________
Address/Location: ___________________________________________________________________________________________
I believe that my answers are correct
I have reviewed the above information with the patient.
.
Have you ever had problems with anesthesia in the past? Ë Yes Ë No
______________________________________________________________
Physician’s Name
Date
Time
______________________________________________________________
If yes, please explain: ________________________________________________________________________________________
Sign your name and put today’s date and time
_______________________________________________
Physician’s Signature
MEDICAL RECORD COPY
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