Microsoft word - dr anderson zieminski beekman.doc

Greensboro Medical Associates, PA
1511 Westover Terrace · Suite 201 · Greensboro, NC 27408 Referred here by (check one): _____Self _____Family _____Friend _____Doctor _____Other Health Professional The name of the physician providing your general medical care: Do you have an orthopedic surgeon? ______ Yes ______ No If yes, Name: Describe briefly your present symptoms: Date symptoms began (approximate): __________________ Diagnosis given? (please list): _____________ Previous treatment for this problem (include physical therapy, surgery and injections—medications to be listed later): Please list names of other practitioners you have seen for this problem: MARITAL STATUS:
EDUCATION (circle highest level attended):
Number of hours worked/average per week:
HOME CONDITIONS:
Do you have stairs to climb? _____Yes _____No If yes, how many?
RHEUMATOLOGIC (ARTHRITIS) HISTORY:
Have you or a blood relative had any of the following? (Check if “Yes”):
Yourself
_____Arthritis (type unknown) ______________ _____Childhood arthritis _______________ SYSTEMS REVIEW:
Please check any of the below listed problems which apply to you: GENERAL: Age when periods began:_____ Periods regular:____Yes ____No How many days apart:______Date of last period:________ Date of last Pap smear:__________ Bleeding after menopause:_____
PAST PERSONAL HISTORY:
Do you now have or have you had (check if “Yes”):
Other significant illness (please list): Any previous fractures? _____No _____Yes Describe: Any other serious injuries? _____No _____Yes Describe:
FAMILY HISTORY:
Do you know of any blood relative who has or has had (check and give relationship): On the scale below, circle a number which best describes your situation: Most of the time, I function………. Because of your health problems, do you have difficulty: (Please check the appropriate response for each question) Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.)……………… _________ Walking?……………………………………………………………………………………_________ Climbing stairs?……………………………………………………………………………._________ Descending stairs?…………………………………………………………………………._________ Sitting down?………………………………………………………………………………_________ Getting up from a chair?……………………………………………………………………_________ Touching your feet while seated?…………………………………………………………._________ Reaching behind your back?………………………………………………………………._________ Reaching behind your head?………………………………………………………………._________ Dressing yourself?…………………………………………………………………………._________ Going to sleep?………………………………………………………………………………_________ Staying asleep due to pain?…………………………………………………………………._________ Obtaining restful sleep?………………………………………………………………………_________ Bathing?……………………………………………………………………………………. ._________ Eating?………………………………………………………………………………………._________ Working?……………………………………………………………………………………._________ Getting along with other family members?……………………………………………………_________ With your sexual relationship?………………………………………………………………._________ Engaging in leisure time activities?……………………………………………………………_________ With morning stiffness?………………………………………………………………………._________ Do you use a cane, crutches, a walker, or a wheelchair? (circle item)…………………………_________ What is the hardest thing for you to do? Are you receiving disability?……………………………………………………………………………………____Yes Are you applying for disability?……………………………………………………………………………….____Yes Do you have a medically related lawsuit pending?…………………………………………………………….____Yes MEDICATIONS:
DRUG ALLERGIES:
Present: (list any medications you are taking at this time. Include such items as aspirin, vitamins, laxatives, calcium supplements, etc.) (Include strength and number medication? Please review this list of “arthritis” medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication, and list any reactions you may have had.

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