Microsoft word - new patient clinical information form, final, 14mar03.doc
William R. Klemme, M.D.
Diplomat, American Board of Orthopaedic Surgery
Practice Limited to Spine Surgery
Adult and Pediatric Spine Surgery
Degenerative and Deformity Conditions
NEW PATIENT CLINICAL INFORMATION FORM
Is your problem related to: Job injury
Briefly describe your main problem/complaint. Also, describe the injury that caused these symptoms, if applicable. How long have you had this problem? FOR PHYSICIAN USE ONLY - HISTORY OF PRESENT ILLNESS (These are preliminary notes; refer to dictation for more details)
Outpatient Center, Suite A, 1125 Sir Francis Drake Blvd., Kentfield, California 94904
Office: 415-485-3500 • Fax: 415-456-0456 • www.williamklemme.md
Using the symbols below, please draw in the location of your symptoms on the diagrams. X
= Pain ○
= Numbness /
= Aching •
= Pins & Needles
If you have NECK PAIN, what percentage is: % Neck and % Arm (Total 100%) If you have ARM PAIN, is this: Right arm Left arm Both arms If you have BACK PAIN, what percentage is:
If you have LEG PAIN, is this: Right leg Left leg Both legs
IF APPLICABLE, mark an X
on the line to indicate your usual degree of pain (0 meaning NO
PAIN and 10 meaning WORST PAIN)
NECK PAIN: 0_____1_____2_____3_____4_____5_____6_____7_____8_____9_____10
ARM PAIN: 0_____1_____2_____3_____4_____5_____6_____7_____8_____9_____10
BACK PAIN: 0_____1_____2_____3_____4_____5_____6_____7_____8_____9_____10
LEG PAIN: 0_____1_____2_____3_____4_____5_____6_____7_____8_____9_____10
What position/activity makes the pain worse/better? WORSE
How long can you STAND
with no or minimal pain: ______minutes. WALKING DISTANCE
with no or minimal pain:
0-50ft _____ 50-200 ft _____ 200-500 ft ____ 500+ ft ____ 1/2 mile+ _____
Do you need SUPPORT
to help you walk? _____Yes _____No If yes, what kind of support?
Do you wear a back or neck BRACE
? _____Yes _____No If yes, what kind of brace?
List below the PREVIOUS PHYSICIANS
(MD, DO, Chiropractor) you have seen for your
Indicate which DIAGNOSTIC TESTS
you have had in evaluation of your main
complaint/problem (please include dates).
Please check which TREATMENTS
you have had for your main problem/complaint and
indicate whether they were helpful.
√ Helpful? Treatment √ Helpful? Treatment √ Helpful?
PAST MEDICAL HISTORY:
Please check below if you have had any of the following:
List any SURGERIES
you have had.
List ALL CURRENT MEDICATIONS
(milligrams, grams) (how many times a day)
Have you taken any of the following drugs previously?
√ Helpful? Medication √ Helpful? Medication √ Helpful?
SOCIAL HISTORY & HABITS:
Marital Status: Single Married Divorced Number of Children: _____
Highest Education Level: High School Equivalency High School Graduate
Full Duty Limited Duty Off Duty per physician Unemployed Retired
If you are NOT
working FULL DUTY
, how long have you been off work? ________________
Have you had a work capacity assessment? ____Yes ____ No
Are you disabled through Social Security? ____ Yes ____ No TOBACCO USE:
Do you currently use Tobacco products? ____Yes ____ No Started Age/Year: __________
If yes, indicate the quantity per day:
Cigarettes _____________ Cigars______________ Chewing Tobacco (snuff) ____________
Have you stopped using Tobacco products? ____ Yes ____ No If so, When? ___________ ALCOHOL USE:
Do you currently consume alcoholic beverages? ____Yes ____ No
If yes, indicate the quantity per day:
Beer _________________ Wine ________________ Distilled spirits ________________
Have you ever been treated for drug or alcohol addiction? ____ Yes ____ No
REVIEW OF SYSTEMS:
Check if you have experienced any of the following:
EYES, EAR, NOSE
Describe current health, age, cause of death, illness, diabetes, cancer,
Date of last MENSTRAL PERIOD:
________________________ MALE PATIENTS:
Date of last PROSTATIC EXAM: _________________________
Rectal test: _____ Yes _____ No Results: _________________________________________
PSA (prostate blood test) _____ Yes _____ No Results: ______________________________
The preceding patient information packet has been reviewed and discussed with my patient.
PHYSICIAN SIGNATURE: _______________________________ DATE: ______________
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