[Hand Surgical Associates] - Health Questionnaire

Health Questionnaire
This form will take approximately 20 minutes to complete.

Please mark the appropriate boxes.

Name:
Email:
Today's Date:

Person Completing Form:	Self Other - Specify
Date of Birth (mm/dd/yyyy):
Right or Left handed?:	Right Left
Current Occupation:

Prior Occupations:

Education (please check all that apply):

Technical School
College

High School
Graduate School

Please Describe Your Main Problem:

Which side is affected?

Right Left Both

If both sides are affected, which is worse?

Right Left

When did it start?

What makes it better?

What makes it worse?

At night, is it better or worse?

Better Worse Same

Describe the pain:

Have you ever had similar symptoms?

No Yes

When?

Have you seen any other doctors for this problem?

No Yes

Please list any other doctors that you have seen for this problem (please bring all your medical records regarding this problem):

Have you retained an attorney for the current problem?

No Yes

Please mark the treatment or tests you have had for this problem (please bring all the results and actual x-ray films regarding this problem)

X Rays	Myelogram	Pain Clinic
Arthrogram	Hand Therapy	Nerve Block
CAT Scan	Occupational Therapy	Trigger Point Injections
MRI	Physical Therapy	Chiropractor
EMG/NCV	Acupuncture

Height:

Weight:

Past Medical History:

Do you have any allergies to medication?

No Yes

Do you have an allergy to penicillin?

No Yes

Do you have an allergy to latex?

No Yes

Please list all other medical allergies to medications.

Are you taking any medication?

No Yes

Are you taking any blood thinners?

No Yes

If yes, please list all medications and doses.

Have you had any operations?

No Yes

If yes, please list all operations.

Do you smoke tobacco?

No Yes

If yes, how much and what kind(s)?

Do you drink alcohol?

No Yes

If yes, how much and what kind(s)?

Are you pregnant?

No Yes

Do you have any of the following problems? (select all that apply)

Heart Trouble	No Yes	Bowel	No Yes
Heart Attack	No Yes	Kidney	No Yes
Aortic or Mitral Valve	No Yes	Bladder	No Yes
Rheumatic Fever	No Yes	Diabetes	No Yes
A Pacemaker	No Yes	Thyroid	No Yes
Circulation Problem	No Yes	Arthritis	No Yes
Stroke/TIA	No Yes	Gout	No Yes
Blood Clot	No Yes	Healing	No Yes
Lung Disease	No Yes	Bleeding	No Yes
Asthma	No Yes	Infectious Disease	No Yes
Emphysema	No Yes	Nervousness/Depression	No Yes
TB	No Yes	Emotional/Psychological	No Yes
Liver Disease	No Yes	Seizures	No Yes
Hepatitis	No Yes	Cancer	No Yes
Gall Bladder	No Yes

Within the past year, have you had any of the following? (select all that apply)

Fever	No Yes	Shortness of Breath	No Yes
Chills	No Yes	Nausea/Vomiting	No Yes
Weight loss/gain > 10 lbs	No Yes	Ear/Nose/Throat Problems	No Yes
Headaches	No Yes	Skin Problems	No Yes
Dizziness/Fainting	No Yes	Bleeding Problems	No Yes
Blind Spells	No Yes	Nervousness/Depression	No Yes
Visual Changes	No Yes	Fractures/Broken Bones	No Yes
Numbness/Tingling	No Yes	Backache	No Yes
Chest Pain	No Yes

Do you have a family history of any of the following problems?

Heart trouble	No Yes	Bowel problems	No Yes
Heart attack	No Yes	Kidney problems	No Yes
Aortic or mitral valve	No Yes	Bladder problems	No Yes
Rheumatic fever	No Yes	Diabetes	No Yes
A pacemaker	No Yes	Thyroid	No Yes
Circulation problem	No Yes	Arthritis	No Yes
Stroke/TIA	No Yes	Gout	No Yes
Blood clot	No Yes	Healing difficulties	No Yes
Lung disease	No Yes	Bleeding problems	No Yes
Asthma	No Yes	Infectious disease	No Yes
Emphysema	No Yes	Nervousness/depression	No Yes
TB	No Yes	Emotional/Psychological	No Yes
Liver disease	No Yes	Seizures	No Yes
Hepatitis	No Yes	Cancer	No Yes
Gall bladder	No Yes