Patient Intake Form Orthopedic Specialty Institute Page 3

12) Do   y ou:    

 

YES  

NO  

Have   c hildren    

 

 

How   m any  

 

Live   a lone  

 

 

If   n o,   w ith   w hom  

 

Use   a   s pecial   d iet    

 

 

Describe  

 

Use   r ecreational   d rugs  

 

 

Describe  

 

Exercise   r egularly  

 

 

How   o ften  

 

Sports/Hobbies  

 

 

What___________________________________________________  

13) Family   H istory  

Member    

If   A live,   A ge   &   H ealth   S tatus  

If   D eceased,   A ge   a t   T ime   o f   D eath   &   C ause  

 

Father  

 

 

 

 

 

Mother  

 

 

 

 

 

Sibling   1  

 

 

 

 

 

Sibling   2  

 

 

 

 

14) Current   V itals:  

Height:   _ ______________     W eight:_______________  

 

15) Chief   C omplaint/Current   I llness:  

a)   I s   y our   p roblem   i n   t he:        

Right   K nee          

Left   K nee  

b)   D escribe   y our   c hief   c omplaint?    

 

 

 

c)   H ow   l ong   h ave   y ou   h ad   t his   p roblem?  

 

d)   I s   y our   p roblem   g etting:           W orse           B etter           S taying   t he   s ame    

e)   W as   t his   a   r esult   o f   a n   i njury?         Yes       No         I f   Y es,   w hat   w as   t he   D ate   o f   I njury?_________________  

If   y es,   p lease   d escribe   h ow   i t   h appened:      

 

 

 

16) Work-­‐Related   I njury:    

a) Job   t itle:    

 

b) How   l ong   h ave   y ou   w orked   f or   t his   e mployer?  

 

c) Date   o f   i njury:    

 

d) Are   y ou:       off   w ork  

 

modified   d uty    

full   d uty    

e) If   y ou   a re   n ot   w orking   f ull   d uty,   w hat   d ate   d id   y ou   l ast   d o   s o:    

 

 

17) If   P AIN   i s   o ne   o f   y our   c omplaints,   p lease   c omplete   t he   f ollowing   q uestions.      

a)

Front       Back       Inside   s urface   o f   k nee         Outside   s urface   o f   k nee           B ehind   k neecap  

b)     Rate   t he   a verage   i ntensity   o f   y our   p ain/discomfort.   ( 0=no   p ain,   1 0=severe   p ain)  

 

0                         1                         2                         3                         4                         5                         6                         7                         8                         9                         1 0  

c)   D escribe   y our   P ain:  

Intermittent    

Constant    

Dull    

Sharp      

Throbbing  

Tight    

Burning    

Tingling  

 

18) Timing    

1)   Is   y our   p ain   w orse   a t   a ny   p articular   t ime   o f   t he   d ay?       Morning     Evening     Night  

2)   Does   y our   k nee   a llow   y ou   t o   s leep   c omfortably?       Yes       No    

19) Activity-­‐Related   S ymptoms:  

1) Is   y our   k nee   c omfortable   a t   r est?  

 

Yes       No  

 

Patient   N ame:    

 

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