Initial Evaluation Form - Orthopedics

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INITIAL EVALUATION FORM
Koman Orthopedics and Sports Medicine
_____________________________________________________________________________
Please briefly describe the injury:
NAME: _______________________________________
_____________________________________________
Age: __________ Today’s Date: __________________
_____________________________________________
Date of Birth: _________________________________
Diagnosis (if you know or have been told)?
_____________________________________________
Height: ______________ Weight: ________________
_____________________________________________
Who referred you to us?
If yes, please give name/address of person/physician:
Previous treatments (other than surgery)?
(medications, physical therapy, injections, bracing)
_____________________________________________
_____________________________________________
Occupation? __________________________________
____________________________________________
Previous surgery for this problem (include dates)
Where is your problem?
(please circle)
Shoulder
Elbow
Wrist/Hand
_____________________________________________
Knee
Hip
Ankle/foot
_____________________________________________
Back
Neck
Other
How severe is the pain? (0 = none, 10 = severe pain)
At rest?
0 1 2 3 4 5 6 7 8 9 10
Which side(s)?
Right / Left / Both
At its worst?
0 1 2 3 4 5 6 7 8 9 10
Dominant Arm?
Right / Left
Do you have night pain?
Yes / No
Problem(s) (please check all that apply):
Pain
Does it waken you from sleep?
Yes / No
Weakness
Instability /giving way /dislocation
Are you currently working?
Yes / No / Retired
Stiffness
Normal job?
Limited duty?
Swelling
Other ___________________________
What makes your problem better?
How did you injure yourself?
_____________________________________________
No injury
Sports (which sport?) _______________
What makes your problem worse?
Motor vehicle accident
Work/ job -
_____________________________________________
Workers claim? Yes / No
Please describe your current limitations?
Date of injury? ________________________________
_____________________________________________
Sports level:
none/recreational/college/ professional
Have you had any previous imaging studies?
How long have you had symptoms?
X-rays
Yes / No
date: ______________
________Days _________Mos. __________ Yrs.
MRI
Yes / No
date: ______________
CT scan
Yes / No
date: ______________
Other
Yes / No
date: ______________

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