Fillable HOWARD W.HARRIS, M.D. - PATIENT QUESTIONNAIRE

Fill Online, Printable, Fillable, Blank HOWARD W.HARRIS, M.D. - PATIENT QUESTIONNAIRE Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

HOWARD W.HARRIS, M.D. - PATIENT QUESTIONNAIRE

On average this form takes 11 minutes to complete

The HOWARD W.HARRIS, M.D. - PATIENT QUESTIONNAIRE form is 1 page long and contains:

  • 0 signatures
  • 2 check-boxes
  • 45 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Office Use Only: Patient ID # Date: / /
HOWARD W.HARRIS, M.D. - PATIENT QUESTIONNAIRE
What activity limitations have resulted from this problem?
Type of Pain (circle all that apply):
Aching
Burning
Constant
Diffuse
Dull
Infrequent
Pounding
Shooting
Sharp
Stabbing
Tearing
Throbbing
What makes the pain worse? (circle all that apply):
Climbing Stairs
Prolonged Sitting
Lying Down
Routine Activities
Weather Changes
Recreational Activities
Other (please list):
What gives you relief? (circle all that apply):
Avoiding Activities
Use of Brace
Cane
Crutches
Walker
Cold Packs
Heat
Exercising
Joint Injections
Physical Therapy
PAST ILLNESSES (Circle all that apply):
None
DVT/Clots
Diabetes
Gastrointestinal Disease
Heart Disease
Cancer (localized - one area)
Hepatitis
HIV
Kidney Disease
Cancer (metastatic - spread)
Lung Disease
Stroke
Rheumatoid Arthritis
Infection in Any Joint
Cholesterol
Osteoarthritis
Thyroid
High blood pressure
Obstructive Sleep Apnea
Blood Clots
Other:
PAST SURGERIES (List with approximate age, including all minor surgeries):
Surgery:
Date:
Physician:
Date: / /
Name: DOB: - -
School/AT:________________________ Home Phone:___________________ Work:_____________________________ Cell:_________________________________
REFERRING DOCTOR:
CHIEF COMPLAINT:
Work Related: Y_____ N ______ DATE OF INJURY/ONSET OF PAIN: ______________________HEIGHT:_____________WEIGHT:_________
Describe the manner in which you were injured (please include where you were when injury occurred and be as
detailed as possible on how the injury occurred):
____________________________________________________________________________________________________________________________________________________
How often do you have the pain/discomfort: Constant / Daily / Weekly
Severity: Mild / Moderate / Intense
Please rate your pain from 1-10: While at rest: ______________ With activity:________________
Since first experiencing symptoms, are you: Improving / Unchanged / Worsening
List current treatments you have tried for this complaint (medications, injections, physical therapy,
surgery) and indicate whether they have helped or not.
Seizure Disorder
_____
_____
_____
_____
_____
_____
_____
_______
____
_____
_____
______
_____
_____
_____
____
_____
FAMILY HISTORY (List the relationship of family member next to applicable health issue):
Bleeding:
Diabetes:
Amputations:
Cancer:
Tuberculosis:
Heart Disease:
Strokes:
High Blood
Pressure:
Other:
SOCIAL HISTORY:
Employer:___________________________________________________ Job Description:_________________________________________________________
Recreational Activities/Exercise:____________________________________________________________________________________________________
Single:_ _ Married:_ _ Divorced:_ __ Widow:__ No. Living Children:__________ No. of pregnancies:_________
Do you smoke: Y N _ _ Approx. amount/day:________ Have you ever smoked:_________________________________________
Do you drink alcoholic beverages?: Y N Type:______________ Approx. amount: ________ Daily / Weekly / Monthly
Recreational Drugs:_____________________________________________________________ Hand Dominance: Left__
Medication List:
___ Right__ ____
Please list any medication ALLERGIES you have:
Allergy
Type of Reaction
Are you seeing a pain management physician? Yes No
If so who is your physician?___________________________________________
Do you have a pain management contract? Yes No
Preferred Pharmacy:___________________________________________ Pharmacy Phone:__________________________________________
Do you have allergies to: Iodine IV Contrast Tape X-ray Dye Latex
Do you use a CPAP or Bi PAP Machine: Yes _ _ No
Notice of Medication and Pharmacy Benefit Management Consent:
Texas Orthopedic Specialists has the permission to obtain formulary information, information about other
prescriptions prescribed by other providers and/or third party pharmacy benefit payors for treatment
purposes.
_____________________________________________________________________________________ ___________________________________________
Signature Date
Current Medications
Dosage (mg’s per day)
_____
Do you have a surrogate decision maker? ____ Yes ____ No
If yes, please name:_______________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

HOWARD W.HARRIS, M.D. - PATIENT QUESTIONNAIRE

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 15 June 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document