Patient Questionnaire Patient InformationToday's Date* MM slash DD slash YYYY Age* Date of Birth* Patient's Full Name* First Last Email* Primary Care Physician Dominant Hand* Right Left I was referred by How 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?* Yes No If no, last date worked* MM slash DD slash YYYY Occupation Employer Please describe your job Race* Prefer not to answer American Indian/ Alaska Native Asian Black/ African American Native Hawaiian/ Pacific Islander White Hispanic/ Latino Non-Hispanic Non-Latino Preferred 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?* Yes No Do you have an attorney for this injury?* Yes No Attorney's Name* First Last Do you smoke?* Yes Former Smoker Never a Smoker Form of smoking* Cigarettes Cigars How often?* Date started* MM slash DD slash YYYY Date stopped* MM slash DD slash YYYY Do you drink alcohol?* Yes No How 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?* Yes No What are the complications* Do you take any blood thinners?*(i.e. Plavix, Aspirin, Coumadin) No Yes Blood Thinner Name(s)* Infection History(check all that apply) Hepatitis B Hepatitis C Hepatitis NANB MRSA Cellulitis Are you pregnant?* N/A No Yes Expected Due Date* 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) allergy Describe reaction Medicine(s) allergy* Describe reaction* Medicine(s) allergy Describe reaction Medicine(s) allergy Describe reaction Latex Allergies?* Yes No Latex Allergy Reaction* Have you ever been tested for Latex Allergy?* Yes No Date of Latex Allergy Test* MM slash DD slash YYYY Testing Physician's Name* Physician's Location* Any Surgical History?* Yes No Surgery* Surgery Date* MM slash DD slash YYYY Surgery Surgery Date MM slash DD slash YYYY Surgery Surgery Date MM slash DD slash YYYY Medications* Yes No MedicationsPlease 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* MM slash DD slash YYYY
