Patient Name:* BODY PART #1 (Use second page if you are being seen for more than one body part) Chief Complaint: Body Part:* Laterality: Left Right Current pain level (No pain 0 - 10 Severe pain): When did this condition start? Have you ever tried any of the following conservative treatment options?* 1. Anti-inflammatory medications such as: Aspirin Ibuprofen Naproxen Indomethacin Meloxicam Celecoxib Diclofenac Other N/A if Other: Dates/Duration: Less than 3 months More than 3 months 2. Physical Therapy:* At least 6 weeks 3 months More than 3 months N/A Date Started 3. Assistive devices:* Cane Walker Crutches Wheelchair N/A Duration: 4. Knee brace:* Yes No Duration: 5. Injections:* Cortisone Gel/Synvisc N/A How many injections: Date of last inj: 6. Exercise program:* Yes No Duration: 7. Weight Loss:* Yes No Duration: Have you ever consulted any other physician regarding this condition?* Yes No Date(s): Doctors Name & Contact Info: Recommended Treatment by this Doctor: Have you ever undergone surgery on this body part?* 1. Arthroscopic (scope surgery): Yes No Date(s): Surgeons Name & Contact Info: 2. Joint Replacement Component/Prosthesis:* Yes No (If known): Date(s): Surgeons Name & Contact Info: 3. Other Surgery:* Yes No (If known): Date(s): Surgeons Name & Contact Info: If Yes, please send the OPERATIVE REPORT to our office as soon as possible before the date of your appointment. If unable to submit beforehand, please bring the report with you. Failure to bring in your medical records may delay your course of treatment. Fall Risk Assessment - General Patient Name:* Date of Birth:* Do you use an assisted device? (walker, cane or crutches): * Yes No Have you fallen within the past year? * Yes No Do you feel a buckling sensation? * Yes No Are you wheelchair or home bound? * Yes No Patient Signature: * Date: * CURRENT MEDICATION LIST & ALLERGIES Patient Name: * Date of Birth: Height: * Weight: * List any Medication Allergies Reaction Severity (none, mild, moderate, severe) No Known Allergies -- Select -- Nausea Itching Hives Swelling Vomiting -- Select -- None Mild Moderate Severe ✖ + Add More Are you a tobacco user? * Yes No LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: Prescription and over the counter medications, herbals, vitamin/mineral/dietary supplement. ALL FIELDS ARE REQUIRED No current medication Name of Current Medication (example: Aspirin tablet) Dosage (example: 325 mg) Frequency/Route of Administration (example: 3 times daily orally) Length of Use ✖ + Add More Pharmacy Information: Please indicate the pharmacy you would like your mediciations sent to: Pharmacy Name:* Pharmacy Telephone Number:* Pharmacy Address:*