Sierra Pacific Orthopaedic & Spine Center

First Name* Last Name* Today's Date*

Age* Occupation* Hand* Right-handed Left-handed

History of Current Problem

What body part is involved? Left Right Both

When did you problem start?

How did injury/problem start?

Where did problem occur?

What treatment have you already had?

Where you injured at work? Yes No

Are you currently working? Regular Work Modified Work Not Working

Patient Medical History Do you have a history of the following problems?

High Blood Pressure	Asthma	Emphysema or COPD
Heart Arrhythmia	Diabetes	Ulcers
Coronary artery disease or	Liver disorder	TB
heart attacks	Rheumatoid arthritis	Arthritis
Cancer	Deep vein thrombus	Polio
Seizures/Epilepsy	Bleeding disorder	Problems with anesthesia
Alcohol use	Tobacco use	Recreational drugs
Sleep Apnea	Claustrophobia	Other
Surgeries / Hospitalizations	Year	Complications







Medications Please list all medications that you currently are taking.
Medication(s)	Dose	Reason for Medication

Do you have a Durable Power of Attorney? Yes No

Family History

Member	Alive	Deceased	Age	Health status or cause of death
Father
Mother
Sister/brother
Sister/brother
Sister/brother
Children
Children
Children

Review of Systems Are you currently having problems with any of the following:

Have you ever had your bone density tested? Yes No When Where