BHARAM - PHF

Patient Name

First NameLast Name

Date of Birth

MonthDayYear

Preferred Name

Sex

Gender

For example: Cisgender woman, Cisgender man, Transgender, Nonbinary, Agender, Genderfluid, Genderqueer, Two-spirit, etc

What are your pronouns?

She/Her; They/Them; He/Him; etc

Email

Referred by

physician name, self, previous patient (Please don't state patient's name for privacy purposes) etc.

Referring (if Providers) Phone#/Address/Specialty

Preferred Pharmacy:

Height

inches

Pharmacy Phone:

Weight

pounds

What are you here for today? Please include body part and side.

(Right/left hip, right/left groin etc.)

ALLERGIES AND SENSITIVITIES

Rows	Allergy	Reaction	Comments
1.
2.
3.

CURRENT MEDICATIONS

Rows	Medication Name	Dosage	Frequency	Comments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

REVIEW OF SYSTEMS AND PAST MEDICAL HISTORY

Rows	Yes	No	If yes, please specify if this a PAST OR CURRENT condition.
Alcoholism
Anesthetic complications
Arthritis
Autoimmune disease
Cancer
Clotting disorder
Deep vein thrombosis
Fractures
Gout
Heart Disease
Hepatitis C
HIV/AIDS
Hyperlipidemia
Hypertension
Infectious disease
Inflammatory arthritis
Kidney disease
Lung disease
Osteoporosis
Smoking
Stroke
Thyroid disease
Other
Other
Other
Other
Other
Other

SURGICAL HISTORY

Rows	Name of Surgery	Date Performed	Name of Surgeon/Location
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Please indicate if anyone in your family has any of the following conditions:

Rows	Paternal or Maternal	Mother	Father	Siblings	Other Family Member	Comments
Alcoholism
Anesthetic complications
Arthritis
Autoimmune disease
Cancer
Clotting disorder
Deep vein thrombosis
Fractures
Gout
Heart Disease
Hepatitis C
HIV/AIDS
Hyperlipidemia
Hypertension
Infectious disease
Inflammatory arthritis
Kidney disease
Lung disease
Osteoporosis
Smoking
Stroke
Thyroid disease
Other

Who is your primary care physician?

What is your primary care physician's phone # / address?

Do you smoke? If yes, how many packs/day and how many years?

If you quit smoking, when?

Do you drink alcohol? If yes, how much and how often?

If you quit drinking alcohol, when?

Do you use recreational drugs?

What is your marital status?

Are you pregnant?

Where were you born?

Do you currently exercise?

What sports or activities do you partake in? What exercise types do you participate in?

What sports or activities did you partake in during adolescence?

(N/A if not applicable)

Smoking status? Check all that apply.

Tobacco use cessation counseling? Check all that apply.

Highest degree obtained?

If in school, what year of school are you in?

FOR EXAMPLE: 8th grade; Freshman in College; Senior in High school; Graduate Student

Are you currently working?

If not working, when was the last time you worked?

What is your current occupation?

EXAMPLE: Student, social worker, finance, physician, teacher

Are you applying for disability?

Are you currently on disability or workers compensation?

Have you been exposed to toxins/poisonous substances at work?

Have you completed physical therapy in the past? If none, write N/A.

Where did you have physical therapy AND what is the name and contact information (phone, email, fax)? If none, write N/A.

For how long did you complete physical therapy? If none, write N/A.

When did you start and end physical therapy? If none, write N/A.

Did you previously have 1 or more injections to the hip, groin, spine, bursa and/or ?

If yes, what injection did you get? If no, write NA.

For example: Anesthetic, cortisone, other

If yes, what body part was injected? If no, write NA.

For example: Right/Left hip, bursa, hamstring, spine.

What side was injected? If you did not have an injection, select N/A.

If yes, who performed the injection (or what facility)? If no, write NA.

For example: Dr. XYZ at Lenox Hill Radiology, etc.

Patient History Form

Family History

Social History

Smoking History

Employment History

Prior Hip and Groin Treatment