Sports Medicine Medical History Questionnaire:
Dr. Tin Jasinovic MD, MHSc, CCFP (SEM)- Sports& Exercise Medicine Physician
Name
First Name
Last Name
What is the date of your appointment with Dr. Jasinovic?
-
Day
-
Month
Year
Date
What is your current weight?
What is your current height?
Are you left or right side dominant?
Left
Right
Ambidextrous
Reason for Today's Visit:
What is the Approximate date that your symptoms started?
-
Month
-
Day
Year
Date
Is this problem due to an Injury?
Yes
No
Please succinctly describe what you were doing when the symptom started:
How do the symptoms limit your activites?
What makes your symptoms worse?
What makes your symptoms better?
What treatment(s) did you already try for your symptoms? Eg. Heat,Rest,Ice,Brace,medicine,physio,massage,etc. (Please list all you have tried including alternative options/remedies)
Which treatment(s), if any, helped? By how much (%) ?
Where did your pain sit on the scale when you were first injured/within the first few days after injury? Ten being the worst.
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
Please rate your current pain of a scale of 1-10. Ten being the worst.
Best
1
2
3
4
5
6
7
8
9
Worst
10
1 is Best, 10 is Worst
Have you had similar symptoms before?
Yes
No
If Yes, please describe:
Have any Images been taken for this problem?
Yes
No
Not Sure
Where were they done? What type of Images? (i.e. x-ray,MRI,etc)
Do you recall the approx. date of the last imaging you had done?
-
Month
-
Day
Year
Date
Has anyone else treated you for this condition?
Yes
No
If Yes, where? (ED,urgent care, another doctor, chiropractor, massage therapist,etc):
Past Medical History
Previous Medical Diagnoses? Please list:
Previous Orthopedic surgeries/ Interventions? Please list:
Allergies? Please List:
Current Medications? Please List:
Social History
Current Occupation:
Hobbies/Activities? (I.e. Sports?)
Are you a Smoker?
Yes
No
If Yes, How much do you smoke per week?
Do you consume alcohol?
Yes
No
If Yes, Average drinks per week?
Do you use Cannabis? (in any way)
Yes
No
If Yes, Grams consumed per week?
Submit
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