Patient Questionnaire

Patient Information

Today's Date*

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*

Occupation

Employer

Please describe your job

Race*

Preferred language*

General Information

In 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*

Date stopped*

Do you drink alcohol?*

Yes
No

How often?*

YOUR Medical and Surgical History

Height*

Weight (lbs)*

Do you have any of the following Conditions?

(Please check all the apply)

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*

Please List any other Medical Conditions

YOUR FAMILY Medical History

Does 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*

Testing Physician's Name*

Physician's Location*

Any Surgical History?*

Yes
No

Surgery*

Surgery Date*

Surgery

Surgery Date

Surgery

Surgery Date

Medications*

Yes
No

Medications

Please list all medications you are taking, including over the counter (OTC) medications:

Pain Level*

Please select a number from 0-10 to indicate your pain level:

Patient's Signature*

First Last

Date*

Patient Information

General Information

YOUR Medical and Surgical History

YOUR FAMILY Medical History

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