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  • Orthopaedic History Form

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    tamikanji
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    This document contains a patient history form for an orthopaedic patient at the University of California Irvine Medical Center. The form collects information about the patient's chief complaint, history of present injury, past medical history, surgeries, medications, allergies, family history, social history including occupation, recreational activities, smoking and drinking habits, and a review of symptoms. The patient and physician review and sign the completed form.

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    history form

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    This document contains a patient history form for an orthopaedic patient at the University of California Irvine Medical Center. The form collects information about the patient's chief complaint, history of present injury, past medical history, surgeries, medications, allergies, family history, social history including occupation, recreational activities, smoking and drinking habits, and a review of symptoms. The patient and physician review and sign the completed form.

    Copyright:

    © All Rights Reserved
    Scarica in formato PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
    17 visualizzazioni3 pagine

    Orthopaedic History Form

    Caricato da

    tamikanji
    This document contains a patient history form for an orthopaedic patient at the University of California Irvine Medical Center. The form collects information about the patient's chief complaint, history of present injury, past medical history, surgeries, medications, allergies, family history, social history including occupation, recreational activities, smoking and drinking habits, and a review of symptoms. The patient and physician review and sign the completed form.

    Copyright:

    © All Rights Reserved
    Scarica in formato PDF, TXT o leggi online su Scribd
    Segnala contenuti inappropriati
    di 3

    University of California Irvine Medical Center

    ORTHOPAEDIC PATIENT HISTORY


    Name:

    Date:

    Age:

    CHIEF COMPLAINT: What orthopaedic problem brings you here today?

    HISTORY OF PRESENT INJURY: How did it happen?

    WORK RELATED? YES


    NO
    HOW LONG HAVE YOU HAD IT?
    HAS IT GOTTEN WORSE RECENTLY?
    WHAT MAKES IT BETTER?
    WHAT MAKES IT WORSE?
    ANY PREVIOUS TREATMENTS?
    PAST MEDICAL HISTORY/ILLNESSES: Any serious medical problems? (Diabetes, rheumatoid
    arthritis, high blood pressure, heart attacks, infections, etc.)

    SURGERIES: (Previous surgery? When & What type of surgery?)


    MEDICATIONS: List all medications you take routinely. Name of medicine and strength. How
    many times a day.
    ALLERGIES: Are you allergic to any medications, foods, prep solutions, or materials?
    FAMILY HISTORY: Any medical problems in your family, Mother? or Father?
    SOCIAL HISTORY: What kind of work do you do?:
    DO YOU PARTICIPATE IN ANY RECREATIONAL ACTIVITIES? ANY OTHER
    INTERESTS?
    DO YOU SMOKE TOBACCO? If so, how much?
    DO YOU DRINK ALCOHOL? If so, how much?
    OTHER INFORMATION?

    Review of Symptoms
    Constitutional: Weight Loss?________Weight Gain?_______Fatigue______
    Skin:

    Rashes?_____________Sores?_______________

    Eyes:

    Visual Difference?____________Eye Irritation?___________

    Ears, Nose, Throat:

    Sore Throat?_____Difficulty Swallowing?_____EarAches?_____

    Gastrointestinal:

    AbdominalPain?____Nausea?____Vomiting?____Jaundice?_____

    Genitourinary:

    Painful Urination?___Bloody Urine?____Urination at Night?____

    Respiratory:

    Chronic Cough?_______Shortness of Breath?________

    Cardiovascular:

    Chest Pain?_____Palpitations?_____

    Musculoskeletal:

    Joint Pain?_____Swollen Joints?_____Sore Muscles?_____

    Neurologic:

    Numbness?_____Weakness?_____

    Hematologic:

    Anemia?_____Bleeding Tendencies?_____

    Reviewed with Patient

    Date

    _____________________

    ____________________

    _____________________

    ____________________

    _____________________

    ____________________

    _____________________

    ____________________

    _____________________

    ____________________

    _____________________

    ____________________

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