Atlanta Riverdale | New Patient Questionnaire – Dominion Orthopaedic & Spine

NEW PATIENT QUESTIONNAIRE

Patient Name*

Date Of Birth

Age*

Date*

Primary Care Physician*

Referred By*

Have you been treated by another physician in our practice? (Please check box)

Dr. John Foster
Dr. Eric Steenlage
Dr. William Sutlive III
Dr. Pinecca Patel
Dr. Nicole Forsythe

Have any family members been treated by Dominion Orthopedic Clinic LLC?*

Yes
No

Please Identify the area(s) in which you are experiencing pain.

Back

Right
Left
Both

Neck

Right
Left
Both

Shoulder

Right
Left
Both

Elbow

Right
Left
Both

Wrist

Right
Left
Both

Hand

Right
Left
Both

Finger

Right
Left
Both

Hip

Right
Left
Both

Thigh

Right
Left
Both

Knee

Right
Left
Both

Shin

Right
Left
Both

Ankle

Right
Left
Both

Foot

Right
Left
Both

Toe

Right
Left
Both

Other

Right
Left
Both

Date Of Injury*

Is you injury work related?*

Yes
No

How did your injury occur?*

Which is your dominant hand?*

Left
Right

How severe is your pain?*

Mild
Moderate
Severe

Describe the onset of your pain.*

How long have you had your pain?*

Describe the course of your pain?*

Increasing
Decreasing
Constant

Describe the pattern of your pain?*

Intermittent
Persistent

What diagnostic tests have you had for this problem?*

MRI
CT
X-RAY

What treatments have you had for this problem?*

Allergies*

Other Allergies?*

Type Of Reaction

FAMILY HISTORY

Heart Disease
Diabetes
Stroke
Bleeding Problems
Hypertension
Kidney Problems
High Cholesterol
Osteoporosis

Please place a check box in all areas where there is family medical history.

Please notify us of which family members are associated with the medical problem outlined above.

PAST MEDICAL HISTORY

Please place a check box in all areas where you have a medical history.

Surgery

Date

Hospital

Additional Surgery

Date

Hospital

Additional Surgery

Date

Hospital

SOCIAL HISTORY

Tobacco Use*

Yes
No
Occasional

How often is tobacco used?

Alcohol Use*

Yes
No
Occasional

How often is alcohol used?

Drug Use*

Yes
No
Occasional

How often are drugs used?

Please List All Current Medications

Are you currently pregnant?*

Yes
No
unknown

Vitals*

Height

*

Weight

Patient Signature*