BHARAM - PHF

Patient History Form
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
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 etc.)
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 *

	Allergy	Reaction	Comments
1.
2.
3.

CURRENT MEDICATIONS *

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

REVIEW OF SYSTEMS AND PAST MEDICAL HISTORY *

	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

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

Family History

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

	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

Social History
Who is your primary care physician? *
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? *

Married Single Divorced Widowed
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? *
Smoking History
Smoking status? Check all that apply. *

Currently an everyday smoker Currently a someday somer Former Smoker Unknown if ever smoked Heavy Tobacco smoker Never Smoker
Tobacco use cessation counseling? Check all that apply. *

Preganncy smoking cessation education Smoking cessation eucation Referred to a stop-smoking clinic Smoking effects education Smoking cessation assistance None
Employment History
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? *
Prior Hip and Groin Treatment
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. *

Right Left Bilateral N/A
If yes, who performed the injection (or what facility)? If no, write NA. *
For example: Dr. XYZ at Lenox Hill Radiology, etc.
Type a question
Hip Outcome Score & Modified Harris Hip Score

Please consider your most symptomatic hip (left OR right, but not both) when answering the following questions:
Hip Pain *

None/Able to ignore it Slight, occasional, no compromise in activity Mild, no effect on ordinary activity, pain after activity, use aspirin/ibuprofen/Tylenol Moderate, tolerable, makes concessions, occasional narcotic Marked, serious limitations Totally disabled
Limp *

None Slight Moderate Severe Unable to walk
Support to walk *

None Cane for long walks Cane all the time Crutch 2 canes 2 crutches Unable to walk
Distance walked *

Unlimited 6 blocks 2-3 blocks Indoors only Bed and chair
Stairs *

Can go up/down normally Can go up/down normally with banister Any method Not able
Socks/Shoes *

With ease With difficulty Unable
Sitting *

Any chair, 1 hour High chair, 1/2 hour Unable to sit, 1/2 hour, any chair
Public transportation *

Able to enter public transportation Unable to use public transportation (such as bus, or airport transportation)
Harris Hip Score
Hip Outcome Score

Please answer every question with one response that most closely describes your condition within the past week. If the activity in question is limited by something other than your hip, mark not applicable.

ACTIVITIES OF DAILY LIVING

	Not difficult at all	Slight difficulty	Moderate difficulty	Extreme difficulty	Unable to do	Not applicable
Standing for 15 minutes
Getting into and out of an average car
Walking up steep hills
Walking down steep hills.
Going up 1 flight of stairs.
Going down 1 flight of stairs.
Stepping up and down curbs.
Deep squatting.
Getting into and out of a bath tub.
Walking initially.
Walking for approx. 10 minutes.
Walking 15 minutes or greater.
Twisting/pivoting on involved leg.
Rolling over in bed.
Light to moderate work (standing, walking).
Heavy work (push/pulling, climbing, carrying).
Recreational activities.

Sports Subscale

	Not difficult at all	Slight difficulty	Moderate difficulty	Extreme difficulty	Unable to do	Not applicable
Running one mile.
Jumping.
Swinging objects like a golf club.
Landing.
Starting and stopping quickly.
Cutting/lateral movements.
Low impact activities like fast walking.
Ability to perform activity with your normal technique.
Ability to participate in your desired sport as long as you would like.

Please answer the following regarding your current symptoms.

Please consider the worst side when answering the following questions:
Your symptoms are at: *

Right hip Left hip Both hips, right worst Both hips, left worst
The location of the symptoms in the hip is: *

Front Side Back - Posterior
Please draw the location of your symptoms in the figures below *
Date of onset of your symptoms *
Was the beginning of the symptoms associated to trauma or sports injury *

Yes No
Please share any details about the beginning of your symptoms:

Rate your hip pain at rest *

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Rate your hip pain during sports or recreational activities *

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Pain is worse with:
Pain is better with:
Please indicate associated symptoms: *

Hip catching, popping or locking Numbness or tingling Low back pain Knee pain - same side Pain with menstrual cycle Pain with intercourse Bowel/bladder symptoms Pain with cough or sneeze None of the above
Please list imaging studies performed and date. Remember to bring the images (CDs) you have to your appointment. *
What are your sport or recreational activities? *
What is your goal in treatment? *
Patient Signature *

Clear
Should be Empty:

Patient History Form

Family History

Social History

Smoking History

Employment History

Prior Hip and Groin Treatment

Hip Outcome Score & Modified Harris Hip Score

Hip Outcome Score

Please answer the following regarding your current symptoms.