Duke Orthopaedics of Raleigh Patient Registration Form FOR US TO PROCESS YOUR CHART, PLEASE COMPLETE FULLY AND PRINT CLEARLY PATIENT INFORMATION: NAME: _____________________________________________ TODAY’S DATE: ______________________________________ BIRTHDATE: ________________________AGE: _________ HOME PHONE #: ______________________________________ ADDRESS: _________________________________________ CELL PHONE #: _______________________________________ ___________________________________________ ________ EMAIL:_______________________________________________ CITY STATE ZIP EMPLOYMENT INFORMATION: OCCUPATION: _______________________________________ EMPLOYER: ________________________________________ WORK PHONE #: ____________________________________ PAYOR INFORMATION: INSURANCE PRIMARY: ______________________________ SUBSCRIBER: _________________________________________ SECONDARY: ______________________________________ SUBSCRIBER: _________________________________________ OTHER INSURANCE: _________________________________ SUBSCRIBER:_________________________________________ SOCIAL INFORMATION: RACE (Circle One): Multi-Racial White Unavailable Black Declined ETHNICITY (Circle One): Hispanic or Latino LANGUAGE (Circle One): English MARITAL STATUS (Circle One): Alaskan-Native Asian Hawaii-Pacific All Other________________________________ Unavailable Spanish Single American-Indian Chinese Married Declined Other____________________________ Other_________________________________________ Domestic Partner Divorced Separated Widowed CHILDREN: SONS? (Yes) (No) DAUGHTERS? (Yes) (No) How Many_______ How Many________ SPOUSE/PARENT NAME (If a Minor): ___________________________________________________________ PRIMARY CARE DOCTOR: ______________________________________________________________________________ I don’t have one ADDRESS: ______________________________________________________________________ ______________________________________________________________________ CITY STATE ZIP PHONE #: __________________________________________________________________________ REFERRING HEALTHCARE PROFESSIONAL: _________________________________________________________________ (MD, PT, Chiropractor, etc.) No one referred me ADDRESS:__________________________________________________________________________ ______________________________________________________________________ CITY STATE ZIP PHONE #:___________________________________________________________________________ PREFERRED PHARMACY:__________________________________________________________________________________ I don’t have one ADDRESS: ______________________________________________________________________ ______________________________________________________________________ CITY STATE ZIP PHONE #: ______________________________ FAX #: ______________________________ ORTHOPAEDIC INITIAL HEALTH HISTORY F NAME:_______________ AGE:______ HEIGHT:________ WEIGHT: ________ M DID YOU BRING X-RAYS? YES NO DID YOU BRING LABS? YES NO WHO REQUESTED THAT YOU VISIT THIS OFFICE? SELFREFERRAL DOCTOR_________________________ ATTORNEY___________________________ WHAT IS THE MAIN REASON FOR THIS VISIT? WHAT BODY PART IS INVOLVED? IF MULTIPLE, CHOOSE WORST NECK BACK SHOULDER L R ELBOW L R HAND L ARM L WRIST L FINGER L R R R R PELVIS L R KNEE L R FOOT L R HIP L R ANKLE L R TOE L R HOW LONG HAS THIS PROBLEM BEEN PRESENT? ________ DAYS WAS ONSET? CONSTANT GRADUAL OR SUDDEN THE PAIN IS ARE YOU RIGHT OR LEFT HANDED? DID YOU HAVE AN INJURY? RIGHT YES LEFT NO WEEKS MONTHS YEARS COMES AND GOES (INTERMITTENT) AMBIDEXTROUS IF SO, WHAT WAS IT? DATE OF INJURY: AT WORK? YES NO IN A MOTOR VEHICLE ACCIDENT? YES NO IF YES, THEN ANSWER: DRIVER PASSENGER RESTRAINED UNRESTRAINED HEAD-ON REAR-ENDED T-BONE PASSENGER SIDE T-BONE DRIVER SIDE AIRBAG DEPLOYED SPEED_________ LITIGATION PENDING? YES NO WHAT SEVERITY LEVEL WOULD YOU USE TO DESCRIBE YOUR PAIN? (ON A SCALE OF 0-10: 0=NO PAIN 10=WORST PAIN 0 1 2 3 4 5 6 7 8 9 10 HOW WOULD YOU DESCRIBE THE PAIN ASSOCIATED WITH THIS PROBLEM/INJURY? CHECK ALL THAT APPLY ACHING PULSATING BURNING SHARP CONTINUOUS THROBBING DULL TINGLING EXCRUCIATING OTHER_________ WHAT ACTIVITIES MAKE THE PROBLEM WORSE? GRASPING STANDING TWISTING GRIPPING WALKING TYPING/REPETITIVE LIFTING CLIMBING STAIRS SQUATTING/KNEELING OVERHEAD REACHING DESCENDING STAIRS OTHER_______ DO ANY OF THE FOLLOWING IMPROVE THE PROBLEM? USING A BRACE/CANE RESTING THE AREA COLD APPLICATION SLEEPING HEAT APPLICATION CORTISONE INJECTION MEDICATION OTHER __________ HAVE YOU HAD OTHER SYMPTOMS WITH THIS PROBLEM? BRUISING SWELLING FEELING OF GIVING AWAY TENDERNESS LOCKING WEAKNESS NUMBNESS/TINGLING OTHER ________ POPPING WHAT HAVE YOU TRIED TO DO FOR THE PROBLEM? CHECK ALL THAT APPLY REST CORTISONE INJECTION PHYSICAL THERAPY SYNVISC/HYALGAN/SUPRAX OTC MEDS (ADVIL, ALEVE, TYLENOL) SURGERY PRESCRIPTION NSAIDS (LODINE, CELEBREX, NAIPROSYN) OTHER ________ NARCOTICS NOTICE AND RELEASE OF MEDICATION HISTORY: I give permission for my physician to access my medication history from the National Surescripts Database. Sign ______________________________________ Date _______________________ DRUG ALLERGIES Are you allergic to any of the following? Please describe the reaction. NO KNOWN ALLERGIES Adhesive Tape____________________________________ Codeine_________________________________________ Erythromycin_____________________________________ Iodine/Betadine___________________________________ Morphine________________________________________ CURRENT MEDICATIONS Penicillin______________________________ Radiographic dyes______________________ Sulfa_________________________________ Tetracycline___________________________ Latex_________________________________ Other______________________________ NONE What medications are you currently taking? Please include both prescription and non-prescription medications. Medications Dose Times per Day _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ ________________________ ________________________ _______________________ ________________________ ________________________ PAST MEDICAL HISTORY:(Check all that apply) □ □ □ □ □ □ □ □ □ □ NONE AIDS/HIV Alcohol Abuse Alzheimer’s Anemia Asthma Cancer_____________ COPD Depression Other □ □ □ □ □ □ □ □ □ ALL NEGATIVE Diabetes Drug Abuse DVT/PE GERD/Reflux Gout Heart Disease Hepatitis High Blood Pressure Kidney Disease □ □ □ □ □ □ □ □ □ FALLS ASSESSMENT: Do you need assistance with ambulation (walking)? Do you have a history of falling within the last 90 days? Osteoporosis Pacemaker Rheumatoid Arthritis Seizures Sickle Cell Anemia Sleep Apnea Stroke Ulcers Use of Blood Thinners (Yes) (Yes) FEMALE PATIENTS ONLY: Are you pregnant, or is there a chance you may be pregnant? First day of last menstrual period ________________ PAST SURGICAL HISTORY: (No) (No) (Yes) (No) ALL NEGATIVE Have you ever had any of the following surgeries? Indicate the year of the surgery: Appendectomy_________________________ Spine Surgery______________________________ Gall Bladder___________________________ Open Heart/By-pass_________________________ Hernia repair__________________________ Orthopaedic Surgery_________________________ Hysterectomy_________________________ Prostate Surgery____________________________ Arthroscopic Surgery___________________ Other (type & year)__________________________ Have you ever had a reaction to surgery or anesthesia? Yes No Describe___________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ FAMILY MEDICAL HISTORY: (Check All that Apply) Condition □ □ □ □ □ ALL NEGATIVE Relationship to Patient Arthritis Cancer Diabetes Heart Disease High Blood Pressure SOCIAL HISTORY Alcohol Use (Circle One): (Yes) _______ Amount _______ Frequency _______ Year Quit (No) (Quit) Drug Use: (Circle One): (Yes) (No) (Quit) Type(s)_________________________________ Years Used:_____________________________ Year Quit: _____________________________ Tobacco Use: (Circle One): (Current Everyday) (Current Someday) Type:___________________________________ (Cigarettes, Cigars, Chewing, Pipe) Year Quit:________________ (Former) (Never) Packs/day_______________________________ REVIEW OF SYSTEMS: (Check All that Apply OR Check All Negative Under Each Section) □ Constitutional All Negative Weight Gain □ □ Weight Change □ □ Fever □ □ HEENT □All Negative □ Headaches □ □ □ Double Vision Ringing in Ears □ □ Respiratory □ □ □ Chills Night Sweats □All Negative Shortness of Breath Cough Wheezing Difficulty Swallowing Genitourinary □ □ □ □All Negative Frequency Urgency Blood in Urine □ □ Cardiovascular All Negative Chest Pain □ □ Feel Heart Beating Hard □ Gastrointestinal All Negative Nausea □ Dark Stool or Blood □ Stool Heartburn □ Fainting Spells □All Negative Musculoskeletal Arthralgias □ Gout □ Osteoporosis □ Skin □All Negative □ □ Rashes Wound □ Neurological All Negative Loss of coordination □ □ Tremors □ □ Vascular □ □ □All Negative DVT/Phlebitis Open wounds that don’t heal □ Seizures Hematologic All Negative Easy bruising □ Easy bleeding □ Everything I have answered above is true and correct to the best of my knowledge. Patient Signature:______________________ Date__/__/__ Reviewed by MD:______________________ Date__/__/__