Microsoft word - patient information - english2007.doc

Bone & Joint Center, P.C./ACES
PATIENT INFORMATION QUESTIONNAIRE
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
Street address City State Zip code
Height: ____feet ____inches
Please check one: I am right-handed or I am left-handed
What kind of work do you do? (Please check one)
Construction Desk job Driver Teacher Executive/Professional Factory Homemaker Retired Sales Student Other _____________________________
If you are not working now, when did you last work? ____/____/____
Does/did it require lifting? Yes No
How often? Rarely Frequently Constantly
How much? 10 Lbs. or less 10-50 Lbs. 50-100 Lbs. More than 100 Lbs.
As part of your work, do you commonly? (Please check all those that apply)
Squat Push Pull Lift overhead Climb ladders/stairs Reach Bend Stoop
Is this a Workman’s Compensation case? Yes No
Company name: ______________________________________ Tel: ( ) ________________________
Company address: _____________________________________________________________________
Street City State Zip code
Is this a legal or third person liability case? Yes No
Lawyer’s name: ______________________________________ Tel: ( ) ________________________
Lawyer’s address: _____________________________________________________________________
Street City State Zip code
Which joint (s) are you having trouble with? (Please check all those that apply)
Right side: Shoulder Elbow Wrist Hand Fingers
Hip Knee Ankle Foot Toes
Left side: Shoulder Elbow Wrist Hand Fingers
Hip Knee Ankle Foot Toes
Back Neck Other (please specify) __________________________________________________ Please circle your one major complaint and please check any other complaints.

Difficulty with: Lifting Putting on clothes/shoes Climbing/descending stairs
Please list any other complaints: __________________________________________________________

Onset of the problem:
Suddenly without known injury on ____/____/____
____ Days ago ____ Weeks ago ____ Months ago ____ Years ago
Gradually since ____/____/____ I do not know when it started
An injury on ____/____/____ At work Other (specify location) _______________________
____ Days ago ____ Weeks ago ____ Months ago ____ Years ago
Overall, since it started, is your problem getting worse or Staying the same?
Have you missed work or practice because of your injury? Yes No
Injured while: (Please check all those that apply)
Other (please specify): __________________________________________________________
Injured during: (Please check all those that apply)
Other (please specify): __________________________________________________________
If this injury was on the job, please fill out this section.

Was any equipment, machinery, and/or object involved in the accident? Yes No If yes, please explain: _______________________________________________________ _________________________________________________________________________
Was the accident reported to your supervisor and/or employer at the time of the injury? Yes No
If this was a motor vehicle accident, please fill out this section.
Were you (please check)? Driver Passenger Pedestrian Were you wearing a seatbelt? Yes No Did you strike your head or lose consciousness? Yes No If you were a passenger, what was your position in the vehicle? _____________________ What kind of vehicle (s) was/were involved in the accident (Please circle your type of vehicle and check off the other) Truck Van Car Motorcycle Other: ____________________ Type of collision: Rear-ended Head-on T-type Sideswipe Struck on the left Struck on the right Multiple vehicles “Daisy chain”
Other: ___________________________________________________
Was your vehicle moving when it was struck? Yes No How fast was it going? _____mph.
Did your vehicle strike another vehicle or object? Yes No Describe:
__________________________
_____________________________________________________________________________________
Was the accident reported to the police? Yes No
Were traffic tickets issued? Yes No If yes, who received the tickets?__________________________
How was the weather? __________________________________________________________________
Other: _______________________________________________________________________________
_____________________________________________________________________________________
If you are experiencing PAIN, please answer this section.
If not, please circle NO PAIN and skip to the next page.
Location of the pain: (Please check all those that apply)

The pain goes to: (Please check all those that apply)
Where did your pain start? _______________________________________________________________ Where did your pain spread to? (if anywhere) ________________________________________________ Do you have any abnormal sensation? (Please check all those that apply) ________________________________________________________________________ Do you have weakness in the arms or legs? Yes No Where? ______________________________________________________________________________ Do you have any problems controlling your bowels or bladder? Yes No
Frequency of pain: (Please check all those that apply)
_________________________________________________________________________
Time of day when the pain occurs? (Please check all those that apply)
Other: _______________________________________________________________________
The pain is:

_________________________________________________________________________
Do you have stiffness in the back/neck? (Please check all those that apply)
_________________________________________________________________________
Have you had back or neck pain before?
Yes No When? _______________________________
What is the MAXIMUM amount of time you could sit in one place?

Less than 15 minutes 15-30 minutes 30-60 minutes 1-2 hours Unlimited What is the MAXIMUM amount of time you could stand in one place?

Less than 15 minutes 15-30 minutes 30-60 minutes 1-2 hours Unlimited What is the MAXIMUM distance you could walk?


Which of the following aids for walking are you currently using?

No aids necessary Brace Cane Crutches Walker Wheelchair
Could you go as far if you couldn’t use an aid such as a cane or crutches? Yes No
What is the MAXIMUM number of stairs that you can climb?

None A few steps ½ Flight 1 Flight 2 or more flights PLEASE CIRCLE THE NUMBER THAT CORRELATES BEST WITH HOW FAR YOU ARE
FROM NORMAL TOWARD THE WORST POSSIBLE SITUATION YOU CAN IMAGINE OR
HAVE SUFFERED.
0 = No pain or limitation at all.
10 = The worst possible pain or limitation that you could imagine How bad is the pain at the worst it’s ever been? How bad is the pain at the best it’s ever been? Does the pain interfere with your lifestyle?
Where is your pain? (Please mark on the drawings where you feel the specific type of pain or sensation)
Use the following symbols to indicate your specific type of pain or sensation:
Burning: XXXX Throbbing: ++++ Sharp: //// Aching: •••• Numbness: ****
What activities or positions make the pain worse? (Please check all those that apply)
Sitting (Driving, airplane, theater, etc.) Carrying things (laundry, groceries, etc.) _________________________________________________________________________
What activities or positions make the pain better? (Please check all those that apply)
_________________________________________________________________________
Have you taken any medication for the pain? Yes No (If so, please check all those that apply)
Pain medications
Anti-inflammatories
Muscle relaxants

Does the medication help? Yes No Only a little bit
Activities you CANNOT perform because of the injury? (Please check all those that apply)

Sitting (driving, airplane, theater, etc.) Carrying things (groceries, laundry, etc.) Continued

Other: ____________________________________________________________________________
I have had to quit some nonsporting recreational activities that I enjoy (Please list) __________________
_____________________________________________________________________________________

How often do you wake up at night or have difficulty going to sleep?
I can sleep but only when I take medicine
I can’t sleep even when I take medicine

Which sports do you (or would like to) participate in but are limited in them? __________________
_____________________________________________________________________________________
Have you or do you participate in competitive sports and at what level? _______________________
_____________________________________________________________________________________
Has your injury ever been treated by your family physician? Yes No
Physician’s name: ________________________________When? _______________________________
Diagnosis: ______________________________________ Treatment? ___________________________
Has your injury ever been treated by an orthopedic or neurosurgeon? Yes No
Physician’s name: ________________________________When? _______________________________
Diagnosis: ______________________________________ Treatment? ___________________________
Has your injury ever been treated by a chiropractor or naprapath? Yes No
Physician’s name: ________________________________When? _______________________________
Diagnosis: ______________________________________ Treatment? ___________________________

Were you ever treated for your injury in an emergency room? Yes No
Hospital: _______________________________________ When? _______________________________
Diagnosis: ______________________________________ Treatment? ___________________________
Have you ever been admitted to a hospital for your injury? Yes No
Hospital: _______________________________________ When? _______________________________
Diagnosis: ______________________________________ Treatment? ___________________________

Have you ever had physical therapy (PT), a brace, or a corset? Yes No
When: _________________________________________ Where? ______________________________
Results: _____________________________________________________________________________

Have you ever had x-rays of your injury taken? Yes No
When: _________________________________________ Where? ______________________________
Results: _____________________________________________________________________________
Have you ever had a myelogram (dye test) done? Yes No
When: _________________________________________ Where? ______________________________
Results: _____________________________________________________________________________
Have you ever had a CAT scan or an MRI of your injury done? Yes No
When: _________________________________________ Where? ______________________________
Results: _____________________________________________________________________________
Have you ever had an EMG/NCVS (electromyelogram/nerve conduction velocity) done? Yes No
When: _________________________________________ Where? ______________________________
Results: _________________________________________Ordering Doctor: ______________________
Have you ever had a chymopapain injection (meat tenderizer)? Yes No
When: _________________________________________ Where? ______________________________
Results: _________________________________________Ordering Doctor: ______________________
Have you ever had spine surgery (laminectomy or spinal fusion) Yes No
When: _________________________________________ Where? ______________________________
Results: _________________________________________Ordering Doctor: ______________________




THANK YOU FOR YOUR PATIENCE IN FILLING OUT THIS FORM!

Source: http://www.bjc-aces.com/PATIENT%20INFORMATION%20-%20ENGLISH2007.pdf