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Department of Orthopedics
JOHN DAWSON, M.D.
Date: ________________
Last Name: _______________________ FirstName:_____________________ M.I._________
DOB: ___________ SS# ________________ HT: ______ WT:________ Age: ________ Sex:__
E-mail Address: __________________________________________________________
Address: _________________________________ City: ____________ State: ___ ZIP: ________
Home#_____________________ Work#____________________ Cell#____________________
Referring Physician:__________________________________ Office#: ____________________
Pharmacy Name: _________________________
Address______________________________ Phone#: _________________
EMERGENCY CONTACT
Name: _______________________________ Relationship: _______________
Home#_____________________ Work#____________________ Cell#____________________
How did you hear about our office? ____________________________________________________________________________
Reason for office visit: _____________________________________________________________________________
History of injury or fracture related to area: Yes __ No __ If yes, list______________________
_____________________________________________________________________________
How long have you had symptoms? _______________________
Pain Severity: Pain Quality: Pain Location:
Mild ___ Aching/Dull____ Front ___
Moderate___ Burning/Tingling ____ Back ___
Severe___ Stabbing/Sharp ____ Side ___
Other________________
Are your symptoms: History of injury to area:
Constant ___ Does your condition effect: Yes __ No __ If yes, list
Episodic ___ Work__ Kneeling __ ______________ Improving___ Sports__ Running __
Worsening ___ Stair climbing __ Sleeping__
Sitting__ Driving __
Do you take pain medications:
Do you use: Yes __ No __
Walker __ Anti-inflammatory __
Wheelchair__ Tylenol __
Cane __ Narcotics __
Brace ___ Supplements __
Other __________________
Cirlce all painful joints: Do you have any Spine/Back Conditions:
Shoulder (R/L) Elbow (R/L) Yes __ No __ If Yes list:
Wrist (R/L) Hip (R/L) Hand (R/L) Cerical/Neck __
Ankle (R/L) Foot (R/L Lumbar/Low Back __
Thoracic/Mid Back __
Have you sought treatment for this condition before? Yes___ No___ If Yes, explain
______________________________________________________________________________
Primary Care Physician: _________________________________________________________________________
Social History
Married / Partner: Employed:
Yes___ No___ Yes___ No___ Retired: Yes___ No___
Spouse / Partner Name: _________________________ Profession: ______________________
Patients Medical History Past Surgical History
(please check conditions you have now or have had in the past) List prior surgeries and dates:
NO YES NO YES Date Surgery
___ ___ Heart disease ___ ___ Cancer __________________
___ ___ High blood pressure ___ ___ High cholesterol __________________ __________________
___ ___ Emphysema ___ ___ Epilepsy __________________
___ ___ Rheumatic Fever ___ ___ Herpes
___ ___ Tuberculosis ___ ___ Venereal Disease
___ ___ Bleeding Disorder ___ ___ Kidney Problem
___ ___ Liver Disease
Allergies and Medications
Medication Allergies: Yes __ No __ If yes, list: _______________________________________
_____________________________________________________________________________
List medications and dosages (attach separate sheet if necessary _______________________
______________________________________________________________________________
Family History
Family history of heart disease: Yes__ No __ If yes, list: ________________________________
List other family health problems: ________________________________________________
______________________________________________________________________________
ROS (circle any of the following symptoms/conditions that you have)
Head-Ears-Eyes-Nose:
Glasses Hearing Loss Sinus Disorder Current Dental Cavities
Pulmonary:
Shortness of breath with activity Asthma Required C-PAP Pneumonia
Heart:
Chest Pain Heart Attack Difficulty Breathing at Night Congestive Heart Failure
Genitourinary:
Painful Urination Difficulty Starting Urination Blood in Urine
Gastrointestinal:
Heart Burn / Reflux Constipation Blood in Stool
Vascular-Lymphatic:
Leg Sweeling Calf Pain with Exercise Blood Clots/DVT Leg Ulcerations
Neurlogic-Musculoskeletal:
Dizziness Black-outs Sciatica Extremity Weakness Extremity Numbness
Hematologic Endocrine:
Anemia Fever/Chills Recent Weight Changes Recent Appetite Changes
Skin- Psychiatric:
Rash Brusing Sking Infection Depression Anxiety Bioplar
Patient Signature: ________________________________________ Date ____/____/_______
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