Health History/Review of Systems

Name:
Date:
MRN:
Height:
Weight:
Referring Physician/PT
City/State of Referring Physician/PT
Age:
Date of Birth:
Occupation:

Affected Knee:
Did you sustain an injury?
If so, when?
If not, how long has/have your knee(s) been bothering you?
Tell us about your current knee condition/injury:
Was the injury work related?
What are you specific concerns?

Present/Past Medical History

(Please check all that apply)


Other:

Current Medications

(include any non-prescription products)

None

Medication

Dosage (mg, mcg, etc.)

Frequency (times per day, as needed, etc.)

Allergies to medication: None
Are you allergic to latex?
Are you allergic to iodine?
Are you allergic go adhesives?

Have you ever had surgery or a notable injury to your RIGHT Knee?
Approximate Date
Description
Have you ever had surgery or a notable injury to your LEFT Knee?
Approximate Date
Description
Previous Fractures/Surgeries (other than knees)
Approximate Date
Purpose
Hospitalizations (other than knees, in the last 10 years)
Approximate Date
Description

If you are over 65 years old, please answer the next two questions...

Have you ever had a DEXA Scan?
If so, when was your last DEXA Scan?
Have you had any falls in the last 12 months?
If so, how many times have you fallen?

Do you currently smoke?

(If you are female, please answer the next two questions)
Are you currently pregnant?
Are you attempting to get pregnant?

Patient Signature*
Name
Date

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