Transcription of OAD Initial History Survey - Orthopedic Associates …
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OAD Initial History Survey - Orthopedic Associates …
Orthopedic Initial History Survey Date:_____ Chart # _____ Provider _____ Patient Name (Please Print) _____ DOB___/___/___ Temp _____ H ___/___ W _____ Age ____ F M Height ___/___ Weight _____ Did you bring x rays? Y N Labs Y N Who requested that you visit this office? Doctor (Name)_____ Self Referral Attorney_____ What is the main reason for this visit? (Chief Complaint) _____ _____ What body part is involved? (Location)Neck Shoulder R L Elbow R L Hand R L Pelvis R L Knee R L Foot R L Back Mid Lower Arm R L Wrist R L Finger R L Hip R L Ankle R L Toe R L How long has this problem been present?_____ Days Weeks Months Years Are you right or left handed?
PAST SURGICAL HISTORY None 3) Have you had any of the following surgeries? Please check the ones that apply and give the date
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