ORTHOPEDIC HISTORY
Name: _________________________________________ Today’s Date: ________________
Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs
Primary Doctor Name and Address:
Referring Doctor Name and Address:
______________________________________ ______________________________________
______________________________________ ______________________________________
If not referred, how did you choose this office? ____________________________________________
Why are you seeing the doctor today?
(body part)
__________________________________________
How long has the pain/problem been present? _____________________________________________
Has the pain/problem worsened recently?
No Yes, how recently?________________________
What started the pain/problem?
________________________________________________________
Quality of the pain: Sharp Burning Dull Aching
How severe is the pain at the location described above?
No Pain Mild Moderate Severe
What makes the pain/problem better?
___________________________________________________
What makes the pain/problem worse?
___________________________________________________
Is the pain (check all that apply): Continuous
Activity Related
Night Pain
Unpredictable
Did this problem start at work?
________________________________________________________
Have you already filed or will you file a Workers’ Compensation claim?
_______________________
Have you missed work because of this problem?
__________________________________________
What ever treatments have you tried?
Physical Therapy/Exercise TENS unit
Narcotic medications
Cass/boot
Massage/Ultrasound
Traction
Anti-Inflammatories
Orthotics
Manipulation
Surgery
Steroid injections
Braces
Are you right hand ___ or left ___?
Previous physicians seen for this problem
Physician
Specialty
City
Treatment
ORTHOPEDIC HISTORY
Medications take for this problem
Name of Medication
Dose
Reason
X-Rays and Tests for this problem:
Results
Date
Location
X-Rays
MRI
CT Scan
Bone Scan
Other
Because of this problem, have you filed or do you plan to file a lawsuit? Yes No
If you are a new patient to our practice, please complete the Comprehensive Health History. If you
have previously completed a Comprehensive Health History during a visit to our practice, have there
been any changes to your medical history, surgical history or medications since that time? Please
describe any changes below:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Responsible party’s signature :____________________________________
FOR OFFICE USE ONLY
I have read and confirmed the above information with the patient.
X __________________________________________________
Alton Orthopedic Clinic
John Stirnaman MD -
Board Certified Orthopedic Surgeon
Michael Taylor MD -
Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. -
Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD -
Rheumatologist
Donald LeMoine PA-C
#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002
COMPREHENSIVE HEALTH HISTORY
Name: _________________________________________ Today’s Date: ________________
Date of Birth:________________ Age: _____ Height: _____ft_____in Weight:_____________lbs
Primary Doctor Name and Address: Preferred Pharmacy (Address/Phone)
______________________________________
______________________________________
______________________________________
______________________________________
PAST MEDICAL HISTORY: Check all that apply None Apply
Heart attack
Asthma
Rheumatoid arthritis
Depression
Heart failure
Tuberculosis
Osteoarthritis
ADHD
Abnormal heartbeat
Emphysema
Gout
Seizures
High blood pressure
Thyroid
Osteoporosis
Migraine
Stroke
Stomach ulcers
Cirrhosis
Cerebral palsy
Blood clots in leg
Gastric reflux
Hepatitis (A, B or C)
Downs syndrome
Blood clots in lung
Hiatal hernia
HIV/AIDS
Spina bifida
Poor circulation
Kidney failure
Bleeding disorder
Neurofibromatosis
High cholesterol
Kidney stones
Anemia
Neuropathy: Hands or Feet
Cancer: _________________________________________________________(type/treatment)
Diabetes: year diagnosed __________
Currently controlled with insulin oral medications diet
Other: __________________________________________________________________________
__________________________________________________________________________________
PAST SURGICAL HISTORY: No Prior Surgery
l
a
ti
p
s
o
H
/
n
o
e
g
r
u
S
e
t
a
D
n
o
it
a
r
e
p
O
Have you every had general anesthesia? No Yes
If yes, have you had any problems related to this? No Yes
Please explain any problems related to general anesthesia: ___________________________________
__________________________________________________________________________________
Alton Orthopedic Clinic
John Stirnaman MD -
Board Certified Orthopedic Surgeon
Michael Taylor MD -
Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. -
Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD -
Rheumatologist
Donald LeMoine PA-C
#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002
COMPREHENSIVE HEALTH HISTORY
MEDICATIONS (prescribed and over the counter): I take no medications
METAL ALLERGIES: No Allergies YES_______________________________(List Metals)
SOCIAL HISTORY:
Work status
Working Homemaker Unemployed Disables On Leave Retired Student
Occupation_________________________________________________________________________
Marital Status: Single Married Divorced Widowed
Children No Yes, How many? ______
Do you live alone? ______ If no, who lives with you? ______________________________________
Are you currently smoking?_____ If yes, how many packs a day?___ For how many years?_______
How many packs a day did you previously smoke? ___ Other forms of tobacco? ________________
Alcohol Use Never Rare Social Frequently (more than twice a week)
Alcoholic Recovering Alcoholic
Illegal Drug Use Never In the past Currently Types of Drugs_____________________
Name of Medication
Dose
Reason
ALLERGIES TO MEDICATIONS: No Allergies
Name of Medication
Reaction (rash, swelling, stomach upset, etc.)
Alton Orthopedic Clinic
John Stirnaman MD -
Board Certified Orthopedic Surgeon
Michael Taylor MD -
Board Certified Orthopedic Surgeon
Aaron P. Omotola, M.D. -
Fellowship Trained in Orthopaedic Sports Medicine
Lesley M. Davila, MD -
Rheumatologist
Donald LeMoine PA-C
#4 Memorial Drive • Building B, Suite 130 • Alton, IL 62002
COMPREHENSIVE HEALTH HISTORY
FAMILY HISTORY: Check all that apply None Apply
Heart problems
Diabetes
Arthritis
Bleeding problems
Seizure
Cancer
High Blood Pressure
Stroke
Gout
Kidney problems
Lung problems
Mental Illness
m
s
il
o
h
o
c
l
A
Blood clots (legs or lungs
Other: _____________________________________________________________________________
REVIEW OF SYSTEMS: (In the past 30 days have you experienced any of the following?)
Fever
Sleep apnea (snoring)
Nausea
Chills
Hoarseness
Vomiting
Weight loss
Cough
Diarrhea
Vision changes
Trouble swallowing
Constipation
Vision changes
Chest pain
Hemorrhoids
Glasses/Contacts
Palpitations
Stomach pain
Hearing loss
Swollen ankles
Urinary difficulty
Dizziness
Shortness of breath
Anxiety
Ear pain
Seasonal allergies
Hyperactivity
Nosebleeds
Skin rashes
Memory loss
Toothache
Swollen glands
Blackouts
Gum problems
Poor appetite
Headache
I have not experienced any of the above symptoms in the last 30 days
Other: __________________________________________________________________________
__________________________________________________________________________________
FOR OFFICE USE ONLY
I have read and confirmed the above information with the patient/family:
Physician Signature:_______________________________________ Date:_______________________