Information Form – Rev. 07/03/13

PATIENT’S INFORMATION

Name:___________________________________________________________________________________

Date of Birth: _______________________________

Today’s Date: _______________________________

Primary Care Physician: __________________________ Referral Source: ____________________________

Age: ________ Spoken Language: __________________ Race: __________ Ethnicity: _________________

Marital Status: Single:_____ Married:_____ Widow:______ Divorced:_______ Partner:______

Right Handed:_________ Left Handed:_________ Male:_______ Female:______

Reason For Today’s Visit: __________________________________________________________________

Is This Due To An Injury? Yes _____ No _____ If Yes, Date Of Injury___________________________

Workers Compensation Claim? Yes _____ No _____ Motor Vehicle Accident? Yes _____ No _____

Litigation Pending? Yes ____ No ____

Circle All Current As Well As Previous Illnesses:

Height: _____________ Weight: ________________ Blood Pressure: ________________

Asthma/Bronchitis / Emphysema Yes / No High Blood Pressure Yes / No

Osteoarthritis/Rheumatoid Yes / No Atrial Fib Yes / No

Stroke/ TIA Yes / No Pacemaker Yes / No

Epilepsy/ Seizure Yes / No Cardiac Stents Yes / No

Thyroid/ Goiter Yes / No

Other____________________________________

Mental Illness Yes / No History Of MRSA Yes / No

Sleep Apnea Yes / No If Complications With Anesthesia Please

Diabetic Type _____ Yes / No Explain_______________________________

History Of Cancer Yes / No Recent Usage Of Cipro/ Levaquin Yes / No

Type ______________________________________ Up to date with Immunizations? Yes / No

Do You Have Any Other Medical Conditions That Affect Your Bones Or Joints? __________

Bronier L. Costas, M.D.

Gary M. Lourie, M.D.

Allan E. Peljovich, M.D., M.P.H.

Jeffrey A. Klugman, M.D.

Joshua A. Ratner, M.D.

Northside Hospital Doctors Centre 980 Johnson Ferry Road NE, Suite 1020

Atlanta, Georgia 30342

Northside/Alpharetta Medical Campus 3400A Old Milton Parkway, Suite 350

Alpharetta, Georgia 30005

Hand & Upper Extremity Surgery Center 993D Johnson Ferry Road NE, Suite 200

Atlanta, Georgia 30342

(404) 255-0226 • www.HandCenterGA.com Bryce T. Gillespie, MD.

Information Form – Rev. 07/03/13

Social History

I Use Alcohol: Never______ Rarely ______ Moderate ______ Daily ______

I Smoke: Never ______ Current Packs/Date______ Quit In ______

Hobbies And Sport(s) Activities I Enjoy: ___________________________________________________

Type Of Work: ________________________________________________________________________

Please List Any Drug Allergies: __________________________________________________________

Please List Any Other Allergies: _________________________________________________________

Please List All Current Medications

Name Dosage Name Dosage

__________________________________________ _______________________________________

__________________________________________ _______________________________________

__________________________________________ _______________________________________

__________________________________________ _______________________________________

If you have more medications that need to be listed, please list on the other side of this paper

Please List All Surgeries

_____________________________ Date: ________ _____________________________ Date: ________

_____________________________ Date: ________ _____________________________ Date: ________

_____________________________ Date: ________ _____________________________ Date: ________

_____________________________ Date: ________ _____________________________ Date: ________

Information Form – Rev. 07/03/13

Name:___________________________________________________________________________________

Date of Birth: _______________________________

Today’s Date: _______________________________

Family History Major Illnesses Please Indicated If Deceased

Mother: ________________________________________________________________________

Father: ________________________________________________________________________

Siblings: ________________________________________________________________________

Family History Of Malignant Hyperthermia? Yes / No

Systems Review- Please Circle Your Answer(s)

Constitutional Symptoms Genitourinary

Good General Health Yes / No Frequent Urination Yes / No

Recent Weight Change Yes / No Painful Urination Yes / No

Fever Yes / No Blood In Urine Yes / No

Fatigue Yes / No Kidney Stone Yes / No

Eyes Gastrointestinal

Wear Glasses Yes / No Loss Of Appetite Yes / No

Wear Contacts Yes / No Nausea Yes / No

Glaucoma Yes / No Vomiting Yes / No

Abdominal Pain Yes / No

ENT Ulcer Yes / No

Hearing Loss/ Ringing Yes / No Hepatitis A/ B/ C Yes / No

Earaches Drainage Yes / No Neurological

Chronic Sinus Problems Yes / No Lightheadedness Yes / No

Nose Bleeds Yes / No Tremors Yes / No

Bleeding Gums Yes / No Paralysis Yes / No

Sore Throat/ Voice Change Yes / No Psychiatric

Cardiovascular Depression Yes / No

Chest Pain Yes / No Memory Loss Yes / No

Palpitations Yes / No Insomnia Yes / No

Swelling Feet Hands Yes / No Nervousness Yes / No

Angina Yes / No

Information Form – Rev. 07/03/13

Pulmonary Hematologic/Lymphatic

Chronic Frequent Cough Yes / No Anemia Yes No

Shortness Of Breath Yes / No Blood Transfusion Yes / No

Exposure To HIV Yes / No

Musculoskeletal Endocrine

Osteoporosis Yes / No Hot/ Cold Intolerance Yes / No

Scoliosis Yes / No Rheumatoid Disease Yes / No

Skin Are You Currently Pregnant? Yes / No

Rash Yes / No

Information Verified With Patient Today With The Following Changes Noted:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Patient Signature:________________________________________________________ Date:_________

Reviewed By:___________________________________________________________ Date:_________

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