New Patient Form - Vanderbilt Orthopaedic Institute, The Vanderbilt Hand Center, Hand And Upper Extremity Page 2
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2SOCIAL HISTORY (Circle Yes or No)
If yes is NOT checked, response will be considered negative.
DO YOU
Smoke or use other tobacco products
Yes
No
If yes, how many packs per day __________________
Drink alcoholic beverages
Yes
No
If yes, average drinks per day ____________________
Please advise your physician of any cultural or spiritual issues that may affect you care:
Marital Status:
Single
Married
Widowed
Divorced
Number of Children (if any):_______________
LIST ANY OPERATIONS HAD:
OPERATION
DATE
SURGEON
HOSPITAL
_____________________________
_______________
___________________
_________________________
_____________________________
_______________
___________________
__________________________
_____________________________
_______________
___________________
__________________________
_____________________________
_______________
___________________
__________________________
_____________________________
_______________
___________________
__________________________
LIST ANY TESTING OR IMAGING THAT HAS BEEN DONE AND WHERE (EXAMPLE: EMG, NCV, MRI, X-RAYS)
__________________________________________
__________________________________________________
__________________________________________
__________________________________________________
__________________________________________
__________________________________________________
ADDITIONAL NOTES & COMMENTS:
PATIENT SIGNATURE: _______________________________________________________ DATE: ________________________
I HAVE REVIEWED THE INFORMATION PROVIDED ABOVE.
PHYSICIAN SIGNATURE: ____________________________________________________ DATE: _________________________
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