Orthopedoc History Form, Appointments, Scheduling, Office Hours, Rockford Spine Center, Northern Illinois

2902 McFarland Road Suite 300 Rockford IL 61107		Phone: 815/316-2100 Fax:815/316-2099 rockfordspine.com
This Form is to be Printed	Orthopedic History & Physical	This Form is to be Printed

Answer all questions to the best of your ability to assist your doctor with your care.

Please be sure to bring this form with you to your appointment, do not drop it off beforehand.

Name	________________________________________		Date: __________
SS# ________________________________________			Birth date: __________
Height: ____FT ____IN Weight: ____LB		Shoe size:____ Age: ________
Dominant Hand: __Right __Left

Referring Doctor (name and address) ____________________________________________________

Internist or Family Doctor (name and address) ____________________________________________

History of Present Illness

1. Chief Complaint (Why are you seeing the doctor today?)	_______________________________________
2. How long have you had this problem?	_______________________________________
3. What started the problem?	________________________________________

	yes	no	when?
4. Has the problem become worse?	___	___	______________
5. Is this problem the result of a car accident?	___	___	______________
6. Is this problem the result of a work accident?	___	___	______________
7. Have you missed any work because of this problem?	___	___	______________
8. Have you missed any school because of this problem?	___	___	______________


9.Signs associated with your chief complaint: check all that apply ___None Apply
Sign	Location	Sign		Location
___ Swelling	_____________________		___ Drainage	_____________________
___ Redness	_____________________		___ Muscle atrophy	_____________________
___ Warmth	_____________________		___ Muscle spasm	_____________________
___ Edema	_____________________		___ Muscle twitching	_____________________
___ Skin changes	_____________________		___ Loss of movement	_____________________
___ Bruising	_____________________		___ Other	_____________________

10.Symptoms associated with your chief complaint: check all that apply ___None Apply
___ Pain	___ Numbness or tingling
___ Weakness	___Other___________________________________________________________

this Orthopedic Medical HISTORY form is to be printed.
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Answer all questions to the best of your ability to assist your doctor with your care.

Please be sure to bring this form with you to your appointment, do not drop it off beforehand.

11. Is your chief complaint made worse by: check all that apply ___None Apply
___ Sitting	___Walking	___ Movement (what body part) ________________
___ Standing	___ Going up stairs	___ Touch (what body part) ___________________
___ Laying down	___ Going down stairs	___ Other _______________________________________

12. Does anything make your chief complaint better? ___Yes ___No
If yes, please list:	______________________________________________________________

13.Rate your pain severity using the following scale: My pain level is: (circle a number) ____ None Apply

1	2	3	4	5	6	7	8	9	10
None Slight Moderate Severe Extreme Could not be worse

14. Describe the quality of your pain? Check all that apply : ___ None Apply
___ Sharp	___ Stabbing	___Shooting	___ Other ______________
___ Dull	___ Throbbing	___ Continuous	___ Other ______________
___ Burning	___ Aching	___ Intermittant	___ Other ______________

15. Treatments for your chief complaint have included: (check all that apply) ___None Apply
___ Physical therapy; exercise	___ Manipulation	___ Anti-inflammatory medication	___ Pain medication
___ Massage and ultrasound	___ Tens unit	___ Traction	___ Braces
___other (list) _____________________________		___other (list) ___________________________________

16. Medicines taken for your current problem:	How much?	How often?
_______________________________________	_______________________	_______________________
_______________________________________	_______________________	_______________________
_______________________________________	_______________________	_______________________
_______________________________________	_______________________	_______________________
_______________________________________	_______________________	_______________________
_______________________________________	_______________________	_______________________
_______________________________________	_______________________	_______________________
_______________________________________	_______________________	_______________________
Write on the back of this form if more medications

17. Previous doctors seen for this problem: ___None

Doctor	Specialty	location (city)	Treatment
_______________________	_______________	____________	________________
_______________________	_______________	____________	________________
_______________________	_______________	____________	________________
_______________________	_______________	____________	________________

this Orthopedic Medical HISTORY form is to be printed.
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Answer all questions to the best of your ability to assist your doctor with your care.

Please be sure to bring this form with you to your appointment, do not drop it off beforehand.

18 Tests done to evaluate your problem: Check all that apply ___ None Apply

Test	Area Tested	Date	Test Location	Test	Area Tested	Date	Test Location
___ Plain X-rays	__________	____	___________	___ Myelogram	__________	____	___________
___ Arthrogram	__________	____	___________	___ Bone Scan	__________	____	___________
___ MRI	__________	____	___________	___ EMG	__________	____	___________
___ CAT Scan	__________	____	___________	___ Other	__________	____	___________
___ Other	__________	____	___________	___ Other	__________	____	___________

Review of Systems: Check all that apply ___ None Apply

___ Fever	___ Heart or chest pain	___ Tooth problems
___ Chills	___ Chest pain with breath	___ Change in urine function
___ Recent weight change	___ Abnormal heart beat	___ Difficulty urinating
___ Very low energy	___ Short of breath with walking	___ Frequent urination
___ Change of vision	___ Short of breathe lying down	___ Blood in urine
___ Blurry vision	___ Swollen ankles or feet	___ Leaking urine
___ Double vision	___ Poor circulation	___ Burning on urination
___ Itchy eyes	___ Persistent cough	___ Swollen Joints
___ Frequent headaches	___ Wheezing	___ Red or warm joints
___ Loss of hearing	___ Green or yellow sputum	___ Broken bones
___ Ear pain	___ Nausea	___ Neck pain
___ Ear drainage	___ Vomiting	___ Back pain
___ Ringing in ears	___ Diarrhea	___ Arm pain
___ Frequent nose bleeds	___ Constipation	___ Leg pain
___ Bad snoring	___ Change in bowel function	___ Seizures
___ Sore throat	___ Stomach pain	___ Blackouts
___ Change in voice	___ Blood in stool	___ Loss of memory
___ Difficulty swallowing	___ Dark or tar looking stool	___ Weakness of arms or legs
___ Easy bruising	___Ulcers	___ Poor balance
___ Easy bleeding	___ Frequent infections	___ Nervous exhaustion
___ Swollen lymph glands	___ Rashes	___ Depression or anxiety
___ Sinus infections	___ Hives	___ New moles or skin lesions
___ Dizziness	___ Gum problems	___ Other

Review of Systems :Women only check all that apply ___None Apply
___ Irregular or missed periods	___Pregnant	___Vaginal bleeding	___Breast lumps or discharge

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Answer all questions to the best of your ability to assist your doctor with your care.

Please be sure to bring this form with you to your appointment, do not drop it off beforehand.

Medical History: Check all that apply ___None Apply
___ Heart attack	___ Osteoporosis	___ Gout	___ Hepatitis
___ Heart failure	___ Pneumonia	___ Ankylosing spondylitis	___ Lupus
___ Angina (chest pain)	___ Asthma	___ Kidney stones	___ Blood clots in legs
___ High blood pressure	___ Bronchitis	___ Kidney failure	___ Blood clot in lungs
___ Stroke	___ Emphysema	___ Transplants	___ Stomach ulcers
___ Diabetes	___ Lung disease	___ Alcohol dependence	___ Bleeding disorders
___ High cholesterol	___ Blood vessel disease	___ AIDS	___ Sickle Cell Disease
___ Rheumatoid arthritis	___ Mental illness	___ Tuberculosis	___ Liver trouble
___ Cancer of ______________________________		___ Other ______________________________

Surgical History: _____ None

Operation	Surgeon	Location	Date
_____________________________	___________________	________________	______
_____________________________	___________________	________________	______
_____________________________	___________________	________________	______
_____________________________	___________________	________________	______

Family History : Check all that apply ___ None Apply
Condition	Which Family Member	Condition	Which Family Member
___ Heart disease	___________________	___ Scoliosis	___________________
___ Stroke	___________________	___ Spine problems	___________________
___ High blood pressure	___________________	___ Kidney failure	___________________
___ Diabetes	___________________	___ Mental illness	___________________
___ Osteoporosis	___________________	___ Bleeding disorders	___________________
___ Rheumatoid arthritis	___________________	___ Anemia	___________________
___ Osteoarthritis	___________________	___ Alcohol dependence	___________________
___ Lupus	___________________	___ Cancer	___________________
___ Sickle Cell	___________________	___ Other (list) _________	___________________

Medications you take: ___None
Medication	Dose	How often	Reason for taking	Side effects
______________	________	__________	______________	______________
______________	________	__________	______________	______________
______________	________	__________	______________	______________
______________	________	__________	______________	______________
______________	________	__________	______________	______________
Write on the back of this form if more medications

this Orthopedic Medical HISTORY form is to be printed.
page 5 of 6

Answer all questions to the best of your ability to assist your doctor with your care.

Please be sure to bring this form with you to your appointment, do not drop it off beforehand.

Shade in where you are having pain. ____Does not Apply

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Draw the location of any other symptoms related to your problem. ___Does not apply
Numbness / Tingling xxxxx	Weakness oooo	Other ++++ (list)_____________


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this Orthopedic Medical HISTORY form is to be printed.
page 6 of 6

Answer all questions to the best of your ability to assist your doctor with your care.

Please be sure to bring this form with you to your appointment, do not drop it off beforehand.

Allergies to Medications: Check all that apply ____ No Known Allergies

Medication	Rash	Wheezing	Swelling	Upset Stomach	Shock	Other (list)
_____________________	____	____	____	____	____	______________
_____________________	____	____	____	____	____	______________
_____________________	____	____	____	____	____	______________

Social History: Check all that apply
Work Status		Occupation _______________	___Veteran __________
___ Homemaker	___ Not working			___ Student
___ Working	___ Retired			___Disabled
Marital Status	___ Married			___ Single
___ Divorced	___ Widowed			___ Co-habitating

I Live:

___ alone

___ with _________________________________

Alcohol Use	___Never	___Rare		___Frequent	Drinks/week______
___Alcohol Dependent			___Recovered Alcoholic
Drug Use	___Never	___Past		___Currently___________________

Tobacco Use Check all that apply
___ Never	___ Cigarettes	__ Cigars		__ Chew	__ Pipe
I have smoked ___ packs of cigarettes per day for ___ years total.
(If less than one pack) I have smoked ___ cigarettes per day for ___ years total.
I have smoked __cigars per day for ___ years total			I have chewed tobacco for __ years total.
I have smoked a pipe for ___ years total.			I Quit ___ chewing ___ smoking ____(date)

My signature confirms I have answered the above questions to the best of my ability.
Patient/Guardian Signature ________________________ (if under 18)	Date ____________________