ORA History Form
Full Name:
*
First Name
Last Name
Today's Date:
*
-
Month
-
Day
Year
Date
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
Email:
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Sex:
*
Female
Male
Dominant Hand:
*
Right
Left
Height:
*
Weight:
*
Primary Care Providers Name:
Other doctors you see and their specialty:
Who requested that you be seen here?
Primary care provider
Emergency room/Urgent care provider
Yourself
Other
Hospital Preference:
*
Genesis East
Trinity Bettendorf
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Reason For Your Visit
Please answer the questions below regarding the orthopedic injury or condition you are seeking treatment for at this time.
What problem are you being seen for today?
*
Right or Left
Right
Left
When did your problem start or what was the date of the injury?
What tests/treatments have you had for this problem:
Rows
When? How Often?
Where?
X Rays
MRI
CT Scan
Bone Scan
Ultrasound
Nerve Test (EMG/NCV)
Radiofrequency Ablation
Spinal Cord Stimulation
Trigger Point Injection
Treatment Details:
Rows
When? How Often?
Where?
Was it helpful?
Physical Therapy
Chiropractic
Brace
Tens Unit
Epidural Steroid Injection
Medications
Radiofrequency Ablation
Spinal Cord Stimulation
Trigger Point Injection
Since my problem started, it is:
Getting better
Getting worse
Unchanged
Has your problem kept you from:
Working
Recreational activities
Activities of daily living like cleaning or dressing yourself
I experience:
Pain
Bruising
Numbness
Tingling
Weakness
Loss of control bowel/bladder
Locking
Catching
Instability
Swelling
Stiffness
Other
If you have sharp pain, how would you describe it:
Sharp
Dull
Stabbing
Throbbing
Aching
Burning
On a scale of 0-10 (10 is the worst) how severe is your pain?
*
Minimal
1
2
3
4
5
6
7
8
9
Severe
10
1 is Minimal, 10 is Severe
The pain is:
Constant
Intermittent
Does the pain radiate, travel, or move?
Yes
No
If the pain radiates, travels or moves - where?
Does your pain wake you from your sleep?
Yes
No
What makes your symptoms worse?
Walking
Stairs
Exercising
Twisting
Kneeling
Direct Pressure
Standing
Sitting
Lying Flat
Bending
Lifting
Coughing/Sneezing
What makes your symptoms better?
Rest/Not Moving
Sitting
Lying
Standing
Exercise/Movement
Elevation
Ice
Heat
Compression/Bracing
Injections
Pain Pills
Other Medications
If there was a specific injury (including work related injuries), please describe what happened:
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Review of Systems
Have you recently had any of these symptoms? Please check all that apply. If none of the below apply, then mark NONE.
Skin
Frequent Rashes
Open Wounds
Itchy/Red
ENT
Hearing Loss
Hoarseness
Difficulty Swallowing
Eye
Blurred Vision
Vision Loss
Double Vision
Lung
Short of Breath
Wheezing
Chronic Cough
Neuro
Headaches
Numbness
Weakness
Frequent Falls
Cardio
Chest Pain
Irregular Beat
Calf Pain
Swelling Feet
Kidney/Bladder
Painful Urination
Kidney Problems
Urinary Infections
Digestive
Heartburn
Nausea/Vomiting
Blood in Stool
Blood
Easy Bruising
Easy Bleeding
Bones/Joints
Osteoporosis
Joint Problems
Broken Bones
Glands
Excessive Thirst
Frequent Urination
Always Hot/Cold
Lymphedema
Psych
Drug Abuse
Alcohol Abuse
Depression
Anxiety
Const
Recent Weight Loss
Frequent Fever
Loss of Appetite
NONE
NONE
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Past Medical History
Do you have a history of any of the following: (Check all that apply)
Bones/Joints
Osteoporosis
Joint Problems
Broken Bones
Current/Past Infections
Pneumonia
Hepatitis A, B, or C
HIV / AIDs
MRSA
VRE
Heart
Open Heart
Stents
Heart Attack
Pacemaker
Circulation
Blood Clots
Clotting Disorders
High Blood Pressure
Stroke
Elevated Cholesterol
Lung
Asthma
COPD
Emphysema
Sleep Apnea
Glands
Diabetes Type 1
Diabetes Type 2
Thyroid
Digestive
Heartburn
Reflux
Ulcers
Dialysis
Kidney
Infections
Stones
Neuro
Neuropathy
Seizures
Psych
Anxiety
Depression
Other
Liver Disease
Cancer
Other
List all past surgeries:
NONE
Appendectomy
Tonsil
Adenoids
C-section/s
Bypass
Gall Bladder
Tubes in ear
Hernia Repair
Oral Surgery
Hysterectomy
Tubal Ligation
Orthopedic Surgery
Other
If you checked a surgery above, please denote what year they occured:
Example: Appendectomy - 2022
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Family History
Family History:
Adopted and family medical history is not known
No significant medical history of any direct relatives
List any major medical problems of your direct relatives. (Examples: Diabetes, Heart Disease, Cancer, Arthritis, etc.)
Rows
Major Medical Problem
Mother
Father
Grandparents
Siblings
Children
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Social History
Do you use tobacco:
*
Yes
No
Quit
If yes, how much?
Do you use alcohol:
*
Yes
No
If yes, how much?
History of substance abuse:
*
Yes
No
Marital Status:
*
Single
Married
Widowed
Children:
*
Yes
No
Are you pregnant?
Yes
No
Unknown
Are you currently working?
*
Yes
No
Retired
Disabled
Type of Job:
Are you a student? If yes, what school do you attend?
*
Grade Level:
Participating in what sports?
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Medication and Allergies
Are you allergic to any medications?
*
Yes
No
If yes, please list the reaction:
Examples: Hives, swelling, rash, stopped breathing, etc.
Other allergies:
Latex
Food
Seasonal
Metal
Other
Have you ever had a reaction to anesthesia?
*
Yes
No
Please list all current prescription and over the counter medications/supplements, along with the dose and frequency:
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Where do you feel pain?
Using the diagram above as a guide, note what areas of your body you feel pain. When describing the pain, use words like "aching, tingling, pins and needles, burning, stabbing" alongside the body part(s) and indicate the right or left side.
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Example: "Left Shoulder - Aching" or "Right Knee - Tingling"
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Patient Signature:
*
Please verify before you submit the completed form:
*
SUBMIT
SUBMIT
Should be Empty: