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Department of Orthopedics
MELVYN A. HARRINGTON, M.D.
Date: ____________
Last Name: _____________________ First Name: ____________________M.I.________
DOB: __________ SS# _______________ HT: ______ WT:________ Age: ____ Sex:___
E-mail Address: _____________________
Address: ____________________________ City________________ State: ____________
Zip: ________ Home: _________________ Work: _________________ Cell: _______________
Referring Physician: _________________________ Office : ___________________________
Primary Care Physician: _______________________________ Office: ___________________
Pharmacy Name: ______________________________ Phone: _________________________
EMERGENCY CONTACT: Name: ________________________ Relationship: ________________
Home: ___________________ Work: ____________________ Cell: ___________________
How did y o u h e a r a b o u t o u r o f f i c e ? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
C h i e f C o m p l a i n t : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
& H I P & L e f t & R i g h t & K n e e & L e f t & R i g h t
W h e n d i d t h e p r o b l e m b e g i n ? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P L E A S E D E S C R I B E Y O U R S Y M P T O M S
C u r r e n t s y m p t o m O n s e t C a u s e S y m p t o m s l a s t S y m p t o m s w o r s e w h e n
& p a i n & d a y s & s p o n t a n e o u s & d a y s & w a l k i n g
& w e a k n e s s & w e e k s & t w i s t i n g i n j u r y & w e e k s & s t a n d i n g
& w a l k i n g & m o n t h s & f r a c t u r e & m o n t h s & s i t t i n g
& l o c k i n g & y e a r s & a u t o a c c i d e n t & y e a r s & s t a i r s
& l o s s o f m o t i o n & w o r k r e l a t e d & l i f t i n g
& n u m b n e s s & f a l l & c a r r y i n g
& s w e l l i n g & o t h e r _ _ _ _ _ _ _ _ _
& g i v i n g o u t
& o t h e r _ _ _ _ _ _ _ _ _ _ _ _
L o c a t i o n o f P a i n P a i n w i t h w e i g h t b e a r i n g P a i n w i t h r e s t N i g h t p a i n
_ _ F r o n t _ _ N o n e _ _ N o n e _ _ N o n e
_ _ B a c k _ _ M i l d O c c a s i o n a l _ _ I n t e r m i t t e n t _ _ M i l d
_ _ S i d e _ _ M i l d S t a i r s O n l y _ _ M o d e rate __Moderate
__Other____ __ Mild Stairs/Walking __Severe __Severe
__ Moderate - Occasional
__ Moderate- Continuous
__ Severe
Symptoms improved by: Use of brace:
__Walking __No
__Exercise __Yes
__Rest If yes, type? ___________________________________
__Ice If yes, did it help? _____________________________
__Heat
__Nothing
__Medication
Names of helpful medications: __________________________________________________________________
____________________________________________________________________________________________
Treatments (surgery, injections, meds, physical therapy, etc) Date Physician Response
__________________________________________________________________________________________________________________________________________________________________________________________
Additional imaging youve had for this condition (MRI/XRAY/CT/Ultrasound):
FUNCTIONAL EVALUATION
SUPPORT Socks/Tie Shoes Sitting
None o with ease o high chair hour or less
Cane long walk o with difficulty o high chair hour or less
Cane always o unable o unable to sit hour any chair
Crutch
Two canes/walker
Two crutches/unable
Stairs Walking
o normal up and down o unlimited o Unable
o normal up and down with rail o > 10 Blocks
o up and down with rail o 5-10 Blocks
o up with rail, unable down o 1-5 Blocks
o unable o Housebound
Please list ALL MEDICATIONS AND DOSAGES that you are currently taking (including over-the-counter meds, herbs, vitamins and supplements)
___________________________________ ___________________________________
___________________________________ ___________________________________
Surgical History:
Procedure Date: Doctor/Hospital/Location
1)____________________________________________________________________________
2)____________________________________________________________________________
3)____________________________________________________________________________
4)____________________________________________________________________________
5)____________________________________________________________________________
6)____________________________________________________________________________
Do you have any history of complications from surgery or anesthesia? __Yes __No
If yes, please explain: ___________________________________________________________
______________________________________________________________________________
SOCIAL HISTORY:
Marital status: __Single __Married __ Divorced __Widowed
Living situation: __Alone __With others __One or __ Two story home # of children: __________
Occupation: __________________________________________________________________________
REVIEW OF SYSTEMS:
Do you now or have you had any problems related to the following systems?
Constitutional Systems GI
Fever __ Yes __No Abdominal pain __Yes __No
Chills __Yes __No Nausea/vomiting __Yes __No
Headache __Yes __No Heartburn __Yes __No
Explain:______________________ Explain:_________________________
Eyes Cardiovascular
Blurred vision __Yes __ No Chest pain __Yes __No
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Pain __Yes __No High blood pressure __Yes __No
Explain:______________________ Explain:________________________
Respiratory Skin
Wheezing __Yes __No Rash __Yes __No
Cough __Yes __No Boils __Yes __No
Short of breath __Yes __No Itching __Yes __NO
Neurological ENT
Tremors __Yes __No Ear Infection __Yes __No
Dizzy spells __Yes __No Soar Throat __Yes __No
Numbness __Yes __No Sinus Problems __Yes __No
Other:________________________ Other:_________________________
Endocrine Hematologic
Excessive thirst __Yes __No Anemia __Yes __No
Too hot-cold __Yes __No Do you take Coumadin? __Yes __No
Tired/sluggish __Yes __No Psychologic
Explain:______________________ Are you generally satisfied with your life?
Genitourinary __Yes __No Painful urination __Yes __No
Frequency of urination __Yes __No
Explain:______________________
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