Patient Questionnaire Patient InformationToday's Date* Date Format: MM slash DD slash YYYY Age*Date of Birth*Patient's Full Name* First Last Email* Primary Care PhysicianDominant Hand*RightLeftI was referred byHow did you hear about Dr. Desio?*(Check all that apply) My Doctor A Friend Magazine Ad Dr. Desio's Website Internet Search Other Other*Presently Working?*YesNoIf no, last date worked* Date Format: MM slash DD slash YYYY OccupationEmployerPlease describe your jobRace*Prefer not to answerAmerican Indian/ Alaska NativeAsianBlack/ African AmericanNative Hawaiian/ Pacific IslanderWhiteHispanic/ LatinoNon-HispanicNon-LatinoPreferred language*General InformationIn this injury related to* Sports MVA Work Comp Slip and Fall Other Other*What sport(s) do you play?Is this injury work related?*YesNoDo you have an attorney for this injury?*YesNoAttorney's Name* First Last Do you smoke?*YesFormer SmokerNever a SmokerForm of smoking*CigarettesCigarsHow often?*Date started* Date Format: MM slash DD slash YYYY Date stopped* Date Format: MM slash DD slash YYYY Do you drink alcohol?*YesNoHow often?*YOUR Medical and Surgical HistoryHeight*4' 8"4' 9"4' 10"4' 11"5' 0"5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6' 0"6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"6' 7"6' 8"6' 9"6' 10"6' 11"7' 0"7' 1"7' 2"7' 3"7' 4"7' 5"7' 6"7' 7"7' 8"7' 9"7' 10"7' 11"Weight (lbs)*Do you have any of the following Conditions?(Please check all the apply) High Blood Pressure Chest Pain Heart Attack Stents Sleep Apnea Cancer Blood Clots Pulmonary Embolism Deep Vein Thrombosis Ulcer Bleeding Disorders Thyroid Disorder Diabetes Insulin Dependent Diabetes Non-Insulin Diabetes Diet Controlled Diabetes (No Medication) Type fo Cancer*Type of Ulcer*Type of Bleeding Disorder(s)*Type of Thyroid Disorder*Arthritis Osteoarthritis Rheumatoid Arthritis Psoriatic Arthritis Any Anesthesia Complications?*YesNoWhat are the complications*Do you take any blood thinners?*(i.e. Plavix, Aspirin, Coumadin)NoYesBlood Thinner Name(s)*Infection History(check all that apply) Hepatitis B Hepatitis C Hepatitis NANB MRSA Cellulitis Are you pregnant?*N/ANoYesExpected Due Date* Date Format: MM slash DD slash YYYY Please List any other Medical ConditionsYOUR FAMILY Medical HistoryDoes any parent, sibling, or child have a history of(Check all that apply) Anesthesia Complications Bleeding Disorders Blood Clots Pulmonary Embolism Please Describe:*Allergies* None Food(s) Medicine(s) Food(s) allergy*Describe reaction*Food(s) allergyDescribe reactionMedicine(s) allergy*Describe reaction*Medicine(s) allergyDescribe reactionMedicine(s) allergyDescribe reactionLatex Allergies?*YesNoLatex Allergy Reaction*Have you ever been tested for Latex Allergy?*YesNoDate of Latex Allergy Test* Date Format: MM slash DD slash YYYY Testing Physician's Name*Physician's Location*Any Surgical History?*YesNoSurgery*Surgery Date* Date Format: MM slash DD slash YYYY SurgerySurgery Date Date Format: MM slash DD slash YYYY SurgerySurgery Date Date Format: MM slash DD slash YYYY Medications*YesNoMedicationsPlease list all medications you are taking, including over the counter (OTC) medications:Pain Level*012345678910Please select a number from 0-10 to indicate your pain level:Patient's Signature* First Last Date* Date Format: MM slash DD slash YYYY
