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Medical & Surgical History Form

Medical & Surgical History

Today's Date *Full Name *Email *Phone Number *ID NumberMedical Aid Number Name:Medical Aid Number:Address *Who is your referring Doctor? *

What is your Gender? * Male Female

Date of Injury:

Please select the site of your injury Neck Shoulder Elbow Wrist / Hand Combination None of the above

Please select if you have current or previous injuries relating to one or more of the following Back Hips Knees Ankles Combination None of the above

I have had it for: A few weeks A few months A long time

Have you had surgery? Yes No

Date of First OperationPlease provide any details about the surgery

Are you currently taking any medication? Yes No

Please list any medication that you may be taking:

Do you have any medication allergies? * Yes No Not Sure

Please describe any allergies that you may have:

Are you left or right handed? * Left Right

Is your injury on the left, right or both? * Left Right Both

What is the nature of your injury? Accident Assault Self Inflicted Elective Surgery Emergency Surgery Unknown Other

Where did your injury occur? At home At work Playing Sport Road Traffic Accident I don't know I have had it for a long time

Provide details

How did your injury occur? Knife Glass Machinery Explosive Crush Degloving Fall Burn Other

Provide details

Type of Wound / Injury Open Closed Burn Skin Loss Avulsion Amputation Dislocation Fracture Other

Describe your injury or onset of symptoms:List previous injuries / symptoms:

Check the conditions that apply to you: Asthma Cancer Cardiac disease Diabetes Hypertension Psychiatric disorder Epilepsy History of Deep Vein Thrombosis History of oral or injection steroids Any metalwork in your hand / upper limb Other None of the above

Please describe any other conditions not listed above:

Check the symptoms that you're currently experiencing: * Tingling / numbness Nerve Pain Joint Pain Tendon Pain Post op Pain Weakness Nodules Joint Stiffness Poor functional use of hands Difficulty typing / using a mouse Difficulty performing Activities of daily living Dropping items Unable to pursue sport / leisure activities Unable to work Other None of the above

Please list any symptoms not described above:

Please rate your RESTING PAIN

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0 = no pain · 10 = worst pain

Please rate your MOVEMENT PAIN

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0 = no pain · 10 = worst pain

Do you smoke? * Always Seldom Never

How often do you exercise? * Always Seldom Never

What type of exercise do you do?Is there anything else that you wish to share?Upload any report that you wish to share, for example an x-ray reportPlease upload your referral from your DoctorPlease upload an image of your initial injury / x-ray Please upload any other images or documents you want to share. You can upload multiple images.

Houghton Medical Suites, Johannesburg · Your information is stored securely and used only for your care or course.