Accessibility Tools

Established Patient New Complaint

  • BODY PART #1 (Use second page if you are being seen for more than one body part)

  • Chief Complaint:

  • Laterality: Left Right
  • 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
  • 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
  • 3. Assistive devices:* Cane Walker Crutches Wheelchair N/A
  • 4. Knee brace:* Yes No
  • 5. Injections:* Cortisone Gel/Synvisc N/A
  • 6. Exercise program:* Yes No
  • 7. Weight Loss:* Yes No
  • Have you ever consulted any other physician regarding this condition?*

  • Yes No
  • Have you ever undergone surgery on this body part?*

  • 1. Arthroscopic (scope surgery): Yes No
  • 2. Joint Replacement Component/Prosthesis:* Yes No
  • 3. Other Surgery:* Yes No
  • 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

  • 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
  • CURRENT MEDICATION LIST & ALLERGIES

    • List any Medication Allergies
    • Reaction
    • Severity (none, mild, moderate, severe)
  • No Known Allergies
  • 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
  • Pharmacy Information:

  • Please indicate the pharmacy you would like your mediciations sent to: