Suffolk Orthopaedic Associates, P.C.                                                            INITIAL VISIT                                     
375 East Main Street, Suite #1, Bay Shore, NY 11706    (631) 665-8790      TODAY’S DATE:

NAME:

PHONE:        BEST DAY NUMBER:                                                           BEST EVENING NUMBER:

EMERGENCY CONTACT NAME:                                                                NUMBER:

WHO REFERRED YOU HERE?

WHAT IS YOUR CHIEF COMPLAINT / WHERE IS THE LOCATION OF YOUR PAIN?

ANY ACCIDENT OR TRAUMA?              

IS THIS A COMPENSATION CASE?                    DATE OF ACCIDENT?            

IS THIS A NO-FAULT CASE?                              DATE OF ACCIDENT?

IF APPLICABLE, PLEASE GIVE DETAILS OF ACCIDENT / INCIDENT

___________________________________________________________________________________________

IS THERE ANY TIME WHEN PAIN IS WORSE?         MORNING            AFTERNOON           EVENING

WHAT DESCRIBES THE PAIN THAT YOU USUALLY FEEL (PLEASE CIRCLE):
Burning             Dull Ache      Pins & Needles      Tingling      Shooting/Radiating          Numbness     Spasm
Sharp      Constant       Intermittent       Increased pain to touch     Warmth to touch     Other:

ANY FACTORS THAT MAKE THE PAIN WORSE?                                               BETTER?

IS YOUR PAIN RELIEVED BY REST?                        ANY POSITION THAT ALLEVIATES PAIN?

ARE YOU EXPERIENCING ANY OF THE FOLLOWING? (PLEASE CIRCLE)  Weight loss      Fever     Weakness     
Headache   Problem walking   Bowel/Bladder problems   Sexual Dysfunction  Swelling    Recent infection

CURRENT MEDICATIONS (PLEASE INCLUDE DOSAGES)_____________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
ALLERGIES TO ANY OF THE FOLLOWING? (PLEASE CIRCLE) Anti-inflammatories /NSAIDS/Aspirin/Anesthesia
Antibiotics / Penicillin / Sulfonamides / Iodine / Dye / Steroids / Lidocaine / Muscle relaxants  Other:

PAST MEDICAL HISTORY (PLEASE CIRCLE IF YOU HAVE A HISTORY OF THE FOLLOWING)
Cancer         Diabetes    Vascular Disease    Heart Disease    Liver Disease    Kidney Disease    Hypertension
Stomach problems    Arthritis    Bleeding problems    Other:

PAST SURGERIES/HOSPITALIZATIONS:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

SOCIAL / WORK HISTORY: (please circle)
Have you ever used illicit / recreational drugs?    Yes/No    If so, are you using currently?     Yes/No
Do you smoke?   NEVER    QUIT    CURRENTLY SMOKE           Alcohol use?   NEVER           SOMETIMES    OFTEN
Are you currently working?  Yes/No    Are you on disability?  Yes/No     Current job:
Does your job involved lifting/bending?   Yes/No   Are you:  MARRIED   SINGLE   DIVORCED   OTHER:

PLEASE ANSWER YES OR NO TO THE FOLLOWING:   Do you feel depressed?                                                    
Do you have issues with anxiety?                  Problems sleeping?                Are you trying to lose weight?                
Any chance that you may be pregnant?                 Do you have any metal device implanted in your body?

WHAT TREATMENTS / TESTS HAVE YOU ALREADY DONE FOR THIS PROBLEM? (PLEASE CIRCLE)           
Physical Therapy?      Medications?       XRAY / MRI / Cat Scan?    Injections/Epidurals    Surgery?