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New Patient Questionnaire: Knee Pain

The document is a new patient questionnaire for David P. Trofa, MD, focusing on a patient named Valentin Canuci, who is experiencing right knee pain. It includes sections for personal information, chief complaint, symptom description, pain level, sports participation, and previous treatments. The questionnaire also asks about medical history, allergies, and any prior complications with anesthesia or surgery.

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15 views1 page

New Patient Questionnaire: Knee Pain

The document is a new patient questionnaire for David P. Trofa, MD, focusing on a patient named Valentin Canuci, who is experiencing right knee pain. It includes sections for personal information, chief complaint, symptom description, pain level, sports participation, and previous treatments. The questionnaire also asks about medical history, allergies, and any prior complications with anesthesia or surgery.

Uploaded by

kb3367
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

David P.

Trofa, MD
Sports Medicine and Shoulder/Elbow Surgeon
New Patient Questionnaire MRN: 1001699106

NAME: Valentin “Val” Canuci DOB: 7 / 6 / 1964 Age: 59 Height: Weight:

Your Referring Physician _______________________________

Your Occupation ____________________________________

CHIEF COMPLAINT
What is the reason for your visit? Right knee pain

_____________________________________________________________________________________

Please describe your symptoms:


Swelling Stiffness Locking Instability
Giving Away Numbness Weakness Tingling
Other:
Current Pain Level (no pain 0 – 10 highest):
0 1 2 3 4 5 6 7 8 9 10
Please mark on the body diagram where you are experiencing pain:

LEFT / RIGHT / BILATERAL ________________________________

When did this condition start?

Please explain how this condition started:

Does anything make the pain better?

Does anything make the pain worse?

Do you participate in any sports?

Level of play (please select):

Professional College High School Recreational

Have you had to modify your activities? Yes No

Are you still able to play sports/exercise? Yes No

Have you had or tried any of the following (please select and describe)?
TYPE Date Location/Results Effective?
X-Ray
MRI / CT
Anti-Inflammatory Medications Yes No
Injections Yes No
Physical Therapy Yes No
Acupuncture / Chiropractic Yes No
Other: Yes No

Please list the physicians that have treated you previously for this problem:

Physician: ______________________ Specialty:_______________________ Phone: ________________

Physician: ______________________ Specialty:_______________________ Phone: ________________

Have you ever had any problems with Anesthesia? Yes / No _______________________________

Have you ever had any complications from prior surgery? Yes / No ___________________________

Allergies: _____________________________________________________________________________
Medications: __________________________________________________________________________
Medical Hx: ___________________________________________________________________________
Surgical HX: ___________________________________________________________________________

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