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ADVANCED ORTHOPEDICS &
SPORTS MEDICINE, P.A. Name: ___________________________________
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Circle |
Describe
all yes responses |
|
|
|
No |
Yes |
______________________ |
|
Eyes |
No |
Yes |
______________________ |
|
Ears, Nose, Throat |
No |
Yes |
______________________ |
|
Lungs, Breathing |
No |
Yes |
______________________ |
|
Digestive |
No |
Yes |
______________________ |
|
Bowels |
No |
Yes |
______________________ |
|
Bladder |
No |
Yes |
______________________ |
|
Heart |
No |
Yes |
______________________ |
|
Stiff or painful joints |
No |
Yes |
______________________ |
|
Bleeding problems |
No |
Yes |
______________________ |
|
High blood pressure |
No |
Yes |
______________________ |
|
Numbness/Tingling |
No |
Yes |
______________________ |
|
Dizziness/Weakness |
No |
Yes |
______________________ |
|
Weight loss or gain |
No |
Yes |
______________________ |
|
Skin rash, itching or lesions |
No |
Yes |
______________________ |
|
Diabetes |
No |
Yes |
______________________ |
|
Thyroid |
No |
Yes |
______________________ |
|
Arthritis |
No |
Yes |
______________________ |
|
Cancer |
No |
Yes |
______________________ |
|
Hepatitis |
No |
Yes |
______________________ |
|
HIV+ |
No |
Yes |
______________________ |
|
AIDS |
No |
Yes |
______________________ |
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Please write below any other information you feel your doctor should know. |
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____________________________________________________________________________ |
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____________________________________________________________________________ |
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PHYSICIAN REVIEW |
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Date ___________ |
Comments _______________________________ |
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Date ___________ |
Comments ________________________________________ |
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Date ___________ |
Comments ________________________________________ |
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