Johns Creek Vickery Village | New Patient Questionnaire

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Johns Creek Vickery Village | New Patient Questionnaire dominionortho 2018-01-26T13:49:06+00:00

Johns Creek Vickery Village | New Patient Questionnaire

Date*
Patient Name*
Date of Birth*
Age*
Primary Care Doctor
Referred By
Sex*
Height*
Weight*
Race*
For Office Use Only
BP
Pulse
Have you been treated by another physician in our practice?
- Dr. Foster III
- Dr. Steenlage
- Dr. Sutlive
- Dr. Patel
- Dr. Forsythe
Reason For Injury (Check All That Apply)
Back
- Right
- Left
- Both
Shoulder
- Right
- Left
- Both
Ankle/Foot
- Right
- Left
- Both
Knee
- Right
- Left
- Both
Elbow
- Right
- Left
- Both
Other
- Right
- Left
- Both
How did you hurt yourself?
Date of Injury
Is this a result of an injury?
- Work
- Auto
- Sport
- Other
Have you been treated by another doctor for this?*
- Yes
- No
If yes, Doctors Name
Did you go to the emergency room?*
- Yes
- No
If yes, which hospital?
Date of trip to emergency room
Were X-rays taken?*
- Yes
- No
Are you seeking a second opinion?*
- Yes
- No
For X-ray purposes, are you pregnant?*
- Yes
- No
How severe is your pain? (Check One)*
- Mild
- Moderate
- Severe
Describe the onset of your pain? (Check One)*
- Gradual
- Gradual, following an incident at work
- Sudden
- Sudden, following an incident at work
- Sudden, following a motor vehicle accident
How long have you had your pain?*
Please enter a number followed by hours/days/weeks/months/years
Describe the course of your pain*
- Increasing
- Decreasing
- Constant
Describe the pattern of your pain*
- Intermitent
- Persistent
What diagnostic tests have you had for this pain?*
- MRI
- CT
- X-ray
What treatments have you had for this pain?*
- NONE
- PHYSICAL THERAPY
- INJECTION
- OCCUPATIONAL THERAPY
- CHIROPRACTIC CARE
Past Surgical History
Surgery Date Hospital Complications
Medications
Medications Additional Medications
Allergies
Untitled*
- None
- Latex
- Erythromycin
- Penicillin
- Codeine
- Sulfa
- Iodine
- IV Dye
- IBProfen
Please check medications allergies and list reactions.
Other allergies, and description of reactions.
Family History
Please name the family members under the related medical problem.
Heart Disease Diabetes Stroke Bleeding Problems
Hypertension Kidney Problems High Cholesterol Osteoporosis
Parents
*
- Living
- Deceased
If deceased, what was the cause?
Siblings
*
- Living
- Deceased
If deceased, what was the cause?
Review Of Symptoms
Constitutional
- Fever
- Weight Gain/Loss
- Loss Of Appetite
Skin
- Rashes
- Lesions that do not heal
- changes in moles
Eyes
- Double vision
- Blurring
- difficulty seeing
Cardiovascular
- Chest pains
- Palpitations
- irregular/rapid heartbeat
Respiratory
- Shortness of breath
- Wheezing
- Spitting blood
- Cough
Digestive
- Abdominal Pain
- Constipation
- Diarrhea
Musculoskeletal
- Stiffness
- Loss of memory
- Joint pain/deformity
- Muscle
- Back pain radiating to arm/leg
Endocrine
- Excessive thirst
- Excessive urination
- heat/cold intolerance
Psychiatric
- Depression
- Anxiety
- Hallucinations
- Sleep disturbances
Urologic
- Pain when urinating
- hesitancy
- bleeding
- incontinence
Gynelogical
- Breast masses
- Pain
- Discharge
- Bleeding problems
Last GYN Visit
Last PAP SMEAR
Neurologic
- Seizures
- Loss of balance/coordination
- Paralysis
Any other symptoms?

Johns Creek Vickery Village | New Patient Questionnaire

Johns Creek Vickery Village | New Patient Questionnaire

For Office Use Only

Reason For Injury (Check All That Apply)

Past Surgical History

Medications

Allergies

Family History

Parents

Siblings

Review Of Symptoms