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History & Physical Form

History & Physical Form

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Please enter your e-mail address: History ROS and Non Ortho PE Orthopaedic PE Spine Vascular Hip Knee Ankle Write in today's date: / / 97 Attending: (other: ) Dictator: (other ) ----------------------------

- History:

Patient name: Hospital number: Age: Date of Birth: / / Gender: male female Race? (other: ) Describe the nature of the current symptoms / problem: Has function at work been impaired by this orthopaedic problem? yes no other Off work due to a present orthopaedic problem? yes no other Current employement situation: (other: ) How much physical labor is currently performed? (other: ) Previous Surgical Treatment: Past Medical History: (date) Medications: Previous Treatment Methods? Non-steroidals: (other: ) Oral steroids: Steroid Injection: If effective, how many weeks of relief: How many injections over the past year: Physical Therapy: What are the patient's goals or expectations for improvement? History ROS and Non Ortho PE Orthopaedic PE Spine Vascular Hip Knee Ankle  
Orthopaedic Physical Exam: Weight? lbs - Assessment of Gait: - Leg Lengths: Are they equal? yes no describe if unequal: - Spine: - see" spine menu: - reflexes: left knee: right knee: left ankle: right ankle: - Motor Exam:
Psoas left: right: Quadriceps left: right: Tibialis Ant left: right: Ext. Hallucis left: right: Gastrocnemius left: right: - Sensation: ) - Vascular Exam: (other: ) History ROS and Non Ortho PE Orthopaedic PE Spine Vascular Hip Knee Ankle

- Hip Joint:

How far can the patient walk? Have ambulatory assistive devices been used? Can the patient put on shoes and socks? - Flexion.... - Left - Right: - Extension - Left - Right: - Abduction - Left - Right: - Trochanteric tenderness: - Push pull test (for loosening of THR components) - Comments: - Radiographs: - PreOp Total Hip Radiographs: - Post Op Evaluation of THR: - acetabular component: - polyethylene wear: - femoral component - comments: - Knee Joint: - see: knee joint: - Effusion: - Joint Line Tenderness: - Flexion.... - Left - Right: - Extension - Left - Right: - specific tests: Lachman: Pivot Shift: - Comments: - Ankle Joint: - Plantar Flexion.... - Left - Right: - Dorsiflexion......... - Left - Right: - Comments: ------------------------------------------ History ROS and Non Ortho PE Orthopaedic PE Spine Vascular Hip Knee Ankle Non Orthopaedic Review of Systems: Head........ Normal Abnormal () Mouth...... Normal Abnormal () CV............. Normal Abnormal () Pulm........ Normal Abnormal () GI.............. Normal Abnormal () GU-Fem.. Normal Abnormal () GU-Male: Normal Abnormal () - Non Orthopaedic Physical Exam: Head and Neck: Normal Abnormal (see below) (other: ) Eyes: Normal Abnormal (see below) Teeth: Normal Abnormal (see below) Cranial Nerves: Normal Abnormal (see below) (comments: ) Chest Normal Abnormal (see below) (other: ) Heart Normal Abnormal (see below) (other: ) Breast Exam: Abdomen: Normal Abnormal Rectal / Prostate: Skin: Normal Abnormal (see below) - involving which part of the body? Nails: Normal Abnormal (see below) - involving which part of the body? Address: address city......... state...... zip..........


Original Text by Clifford R. Wheeless, III, MD.