robynmidgley.comforms

Patient Medical & Surgical History Form

Patient / Therapist Medical & Surgical History

Therapist Full NameTherapist Email AddressPatients Full Name

Patients Gender? Male Female

Is the patient currently taking any medication? Yes No

Please list the medication they are taking:

Does the patient have any allergies? Yes No Not Sure

Please describe any allergies that they may have:

Are they left or right handed? Left Right

Is their injury on the left, right or both hands / upper limbs? Left Right Both

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

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

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

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

Describe their injury or onset of symptoms:Are they claiming compensation for their injury?Have they previously injured their hand or attended hand therapy?List previous injuries:

Check the conditions that apply to them: 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

Please describe any other conditions or problems not listed above:

Check the symptoms that they are 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

Please list any symptoms not described above:Please rate their RESTING PAIN on a scale of 1-5 where 1 STAR describes NO PAIN and 5 STARS describes EXTREME PAINPlease rate their MOVEMENT PAIN on a scale of 1-5 where 1 STAR describes NO PAIN and 5 STARS describes EXTREME PAINDo they smoke?Do they have a history of using illegal drugs?Surgery%20Therapy%20Summit%20email%20signature.62efc91a0550a3.05066400ImageImagePlease upload a video of their hand / injury as it presents today or recentlyPlease upload a video of their hand / injury as it presents today or recentlyPlease upload a video of their hand / injury as it presents today or recently

Describe the movement pattern that they present with: Intrinsic Plus Pattern Intrinsic Minus Pattern Not Applicable I don't know

Do they give consent to a third party assessment by Robyn Midgley?Do they give consent to sharing their journey and images on the Hand Consult SA Social media pages? This will be anonymous.

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