INITIAL HISTORY SURVEY - Page 2
(M/S) 1. Have you had a prior problem with this same Orthopaedic condition in the past? Y / N
    Explain:_________________________________________________________________________________
    _______________________________________________________________________________________
    Do your other joints have: Morning stiffness Joint Pain/Swelling Back pain Gout
(Please check any that apply to you, or mark 'None')
None
 Year - Explain Details/Comments
(CON) 2. Weight loss Frequent fever Loss of appetite    
(EYE) 3. Blurred vision Double vision Vision loss    
(ENT) 4. Hearing loss Hoarseness Trouble swallowing    
(CV) 5. Chest pain Palpitations    
(RS) 6. Chronic cough Shortness of breath    
(GI) 7. Heartburn Ulcers Nausea/vomiting    
    Blood in stool Stomach ache w/ anti-inflammatory pills    
(GU) 8. Painful urinations Blood in urine Kidney problem    
(SK) 9. Freq. rashes Skin ulcers Lumps Psoriasis    
(NEU) 10. Headaches Dizziness Seizures    
(PSY) 11. Depression Drug/Alcohol addict. Sleep disorder    
(ENP) 12. Excessive thirst Excess urination Heat/Cold intolerance    
(HEM) 13. Easy bleeding Easy bruising Anemia    
Are you under the care of another physician for the above non-orthopaedic problems? Y / N
PAST MEDICAL HISTORY
1. Have you ever had Heart attack? _____Year? High Blood Pressure Blood Clots ____ Year? Stroke
  Osteoporosis Ulcers Reflux Asthma COPD Cancer (location) ___________ Diabetes
  High Cholesterol Congestive Heart Failure Thyroid dysfunction Rheumatoid Arthritis Gout
  Other _______________________________________________________________________________
2. PAST HOSPITALIZATIONS (Not for Surgery) None _____________________________________________
3. PAST SURGICAL HISTORY: What operations have you had? When? None __________________________
  _______________________________________________________________________________________
  _______________________________________________________________________________________
4. Have you ever had a reaction to anesthesia? Y / N
5. ARE YOU TAKING, OR HAVE YOU EVER TAKEN BLOOD THINNERS? Y / N --- If 'Yes', which one? ____________
  What Medications do you take? (Please list with dosage) None
  ____________________________________________     ____________________________________________
  ____________________________________________     ____________________________________________
6. ARE YOU ALLERGIC TO ANY MEDICATIONS? Y / N --- If 'Yes', list and describe reaction below.
  _______________________________________________________________________________________
  _______________________________________________________________________________________
FAMILY HISTORY: Have any direct relatives had any of the following disorders? If so, which relative?
  * Any direct relative with the same Orthopaedic condition you are being seen for today? Y / N
Diabetes _______________ High Blood Pressure _______________ Heart Disease _______________
Rheumatoid Arthritis _______________ None
SOCIAL HISTORY   Tobacco use? Y / N --- How long? _____ Packs/day ___      Alcohol use? Y / N --- How often? _____
Marital history: M  S  D  W      How many people live with you? _____      Occupation ____________________________
Are you currently working? Y / N --- If 'No', how long have you been off work? _________________________________
Employer: ___________________________________________________________________________________
Reviewed for Completeness by: ________________________________ Date: _______________________
Reviewed by MD: ___________________________________________ Date: _______________________