New Patient Form - Kerlan

FOOT & ANKLE PATIENT HISTORY & QUESTIONNAIRE
KERLAN-JOBE ORTHOPAEDIC CLINIC
!
NAME: _______________________________________________________________________ DATE: _____/______/__________
SEX: M
F
HEIGHT: __________
WEIGHT: __________
DOB: ______/_______/___________
OCCUPATION: __________________________________________________
AGE: ___________
Currently working? Y N ! if NO, date last worked: ____/____/_______
REFERRED BY: _____________________________________________________________________________________________
REASON FOR VISIT: _________________________________________________________________________________________
LOCATION OF SYMPTOMS:
RIGHT
LEFT
ANKLE
FOOT
HEEL
ARCH
▪ ONSET OF INJURY / SYMPTOMS: ____/____/_______ ▪ SYMPTOMS RELATED TO? WORK
TOE
SPORT
Other: ____________________
ACTIVITY (TYPE: ____________________)
HOW DID THE INJURY / SYMPTOMS OCCUR? ___________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
PREVIOUS RELATED INJURY / SYMPTOMS: _____________________________________________________________________
___________________________________________________________________________________________________________
SEVERITY OF SYMPTOMS (please circle answers):
0 (mild)
1
2
3
4
5 (moderate)
6
CHARACTER OF SYMPTOMS dull sharp ache burning throbbing cramping shooting
7
other:
8
9
10 (severe)
________________________
TIMING OF SYMPTOMS morning afternoon evening work sleep bend squatting climbing
other:
____________________
DURATION OF SYMPTOMS all-day morning afternoon evening minutes hours intermittent
other:
____________________
ASSOCIATED SYMPTOMS swelling bruising tenderness instability locking numbness tingling
ACTIVITY LIMITATIONS stand walk run jump stairs
other:
RESULT
PHYSICAL THERAPY
MRI
BRACES / BOOT
CT
OTHER:
ORTHOTIC
INJECTION
Naproxen
Tylenol
□ None
TREATMENTS
X-RAY
MEDICATION Ibuprofen
_________________
_____________________________________________________
PREVIOUS TESTS OR TREATMENTS FOR THIS CONDITION (please circle answers)
TESTS
other:
RESULT
Other:
PREVIOUS FOOT & ANKLE SURGERIES / PROCEDURES (list procedures & dates):
□ None
PREVIOUS TREATING DOCTORS / PRACTITIONERS (list names & dates):
□ None
USING THE PAIN DIAGRAM BELOW, INDICATE SYMPTOM LOCATION (X) AND SEVERITY (1) mild (2) moderate (3) severe
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Patient Statement: “To the best of my knowledge, the provided information is accurate”
Signature _____________________________________________ Date _____________
Reviewer _____________________________________________ Date _____________