Patient Questionnaire for Fred V. Orcutt~ M.D.
Dear Patient:
You have been scheduled for an evaluation which will be conducted at my offce.
The report) which I shall prepare, wiH be a fai and 0 bjective assessment of your physical condition
and an evaluation of
those effects upon you, which your injur .may have caused. It is importt tht
the report include inormtion about your entie health history, which will assist in evaluating the
effect of
the injur upon you. For ths reason, it would be very helpfu if
you would be kind enough
to fill out ths Questionnaire as completely and accurately as possible. I shall attest to the trth and
objectivity of
this report under penalty ofperju.-y. For ths reason and because of
medical ethcs, the content and opinions of
my personal and
ths report are not inuenced by the par who may have
ordered the report.
It is most importt tht I be in possession of as much inormation as can be provided to write the
best possible report. Medical records, imaging studies, job assessment and other reports have been
the most importtand-mostcredible inormation. In
filling out ths form accuracy and completeness are most importt. For these reasons, I would
appreciate if
you would fil in ths Questionnre as completely as possible.
pr()vided. _You, the patient, are the source of
Imagg stdies, such as x-rays, MRs and CT scans, represent the most importt information,
which I very much need to prepare a fai and complete report. It is very much in your interest that
I am provided with these importt stdies as films, not only reports. If you could brig these
studies with you, it would be most helpfu.
Than you in advance for your coopetion.
Fred V. Orcutt, M.D.
Page 1
PATIENT INORMTION:
1. Full
legal Name:
Las
2.
Date of
bir:
Fir
Middle
i 9 Gender: M F
Month
4.
Middle
Maiden or other names:
(Names used in medical records)
3.
Firt
Day
Present Age:
Year (Circle)
years old
5. Social Securty Number:
6.
Weight before injur:
7.
Curnt height:
feet;
8.
Curent weight:
pounds
9.
Which harddo you wrte with: (Circle one)
pounds
inches;
Right
tota inches
Left
L-
EMPLOYERINORMTlON:
At tie of injur Company
Telephone number
Street Addrs
City
Stae
Zip Code
CHIF COMPLAI:
In your own words, write the importt problems, which you are experiencing, that are related to your injur.
Patient's statement:
"
"
Page 2
JOB DESCRIION AT TIME OF INJUY:
Wht is your job title?
Hours worked per day:
hours.
days.
Days per week:
Descrbe a tyical workday:
Maxum lifted:
pounds.
A verage lifted:
pounds.
How often?
How
often?
HISTORY OF INJUY: In your own words, wrte about the injur.
Place of injur (location or address):
What were you doing just before the injur?
Date and Time of injur:
AM / PM
Day
Month
Year
Tíme
(Circle One)
Did you report the injur to your employer or supervisor: (Circle One) Yes No
When did you report injur to employer?
AM / PM
Month
Day
Name of person, to whom you report the injur:
Witness to injur (if any):
Page 3
Year
Time
(Circle One)
What happened to cause the injur?
What injures did you susta (what body pars and how injured)?
Did your symptoms come on at the time of injur? (Circle One)
Yes
No
Day
Year
If no, describe when and over what period they occured:
If no, when did you realiz tht you were injured? Date:
Month
Explain:
What happened afer the injur? Could you walk? Where did you go?
Date disability staed (Any tie off work?):
Month
Has disability ended? (Circle One) Yes No
Day
If yes, date disability ended:
Month
Page 4
Year
,-
Day Year
HISTORY OF TREATMENT AND COURE:
Initial Treatment:
When were you
first
treated for your injur?
Month
Day
Year
Did your employer send you for initial treatment? (Circle One)
Yes
No
Did you seek initial treatment on your own? (Circle One)
Yes
No
Were you taen to an emergency room or hospitalied? (Circle One)
Yes
No
Name of
hospita / emergency room:
Were you admtted? (Circle One)
City:
Yes
No
,-
Date discharged:
Month
Date
Year
Name of treating doctor:
Describe treatment, tests and x-ray studies:
Did the doctor say what was wrong with you (diagosis)? (Circle One)
Yes
No
Were you told tht more treatment wa necessar? (Cirle One)
Yes
No
Did the doctor restct or modif your work activities? (Circle One)
Yes
No
Yes
No
Explain diagnosis:
Were you told to stay off
work? (Circle One)
Please list all doctor, M.D.'s, D.O.'s, chiopractors, etc., whom you have seen (in the order you saw them):
Doctor/Facilty #1: City:
Degree aId specialty:
Describe treatment and/or test:
Yes No Explain:
Did the doctor state a diagosis: (Circle One)
Date tratment staed:
Month Date
Stopped:
Year Month
Number of treatment:
Lengt of
Page 5
treatments:
Date
'Year
Explai:
Yes No
Did you get better? (Circle One)
/
Are you stll treating with ths doctor? (Circle One)
If
Yes
No
Yes
No
yes, how often? _ times per week.
Did ths doctor tae you off
work? (Circle One)
If yes, disability sted:
Stopped:
Month
Yea
Date
Month
Date
Year
Did the doctor modif work activities? (Circle One)
Yes No
Did the doctor say you needed more treatment? (Circle One) Yes No
Did the doctor prescribe physical therpy? (Circle One)
Yes No
Did the doctor refer you to another physician? (Circle One) Yes No
Explain to whom and why?
City:
DoctorlFacilty #2:
Degree and speCiàlty:
Describe treatment and/or test:
Yes No Explain:
Did the doctor stte a diagnosis: (Circle One)
Stopped:
Date treatment sted:
Year Month
Month Date
Number of treatment:
Did you get better? (Cirle One)
Date
'Yea
Lengt of treatments:
Yes No
Explain:
with ths doctor? (Circle One) Yes No.
If yes, how often? _ times per week.
Are you stil treating
Did tls doctor tae you offwork? (Circle One) Yes No
If yes, disabilty sted:
Stopped:
Month
Date
Did the doctor modif work activities? (Circle One)
Year
Yes No
Did the doctor say you needed more treatment? (Circle One ) Yes No
Did the doctor prescribe physica therapy? (Circle One)
Yes No
Did the doctor refer' you to another physician? (Circle One) Yes No
Page 6
Month
,-
Date Year
Explai to whom and why?
City:
DoctorlFacilty #3:
Degree and specialty:
Describe treatment and/or tests:
Yes No Explain:
Did the doctor stte a diagnosis: (Circle One)
Stopped:
Date treatment staed:
Year Month
Month Date
Number of
treatment:
Date
Year
Lengt of treatments:
Did you get better? (Circle One)
Yes No
Explai:
--
Stopped:
Date
.¥ear
,
Month
Date Year
Did the doctor modify work acvities? (Circle One) Yes No
Did the doctor say you needed more treatment? (Cirle One) Yes No
Did the doctor prescribe physica therapy? (Circle One) Yes No
Did the doctor refer you to another physician? (Circle One) Yes No
Explai to whom and why?
Doctor/Facilty #4: City:
Degree and specialty:
Describe treatment and/or tests:
Yes No Explai:
Did the doctor stte a diagnosis: (Circle One)
Stopped:
Date treatment sted:
Month Date
Year Month
Number of treatment:
Did you get better? (Circle One)
Leng of treatments:
Yes No
Explain:
Are you stl treatig with ths doctor? (Circle One) Yes No
If yes, how often? _ times per week.
Page 7
Date
Yea
Did ths doctor tae you off work? (Circle One)
,-
Yes No
If yes, disabilty sted:
Stopped:
Month
Date
Did the doctor modif work activities? (Circle One)
Year
Month
Date Year
Yes No
Did the doctor say you needed more treatment? (Circle One) Yes No
Did the doctor prescribe physical therapy? (Circle One) Yes No
Did the doctor refer you to another physician? (Circle One) Yes No
Explain to whom and why?
l-more doctors/facilties, use additional sheet.
List major imaging studies done (such as MRs, CT scans, EMGs, etc.) with locations:
Study:
Locauon
Month
Day
Year
Location
Month
Day
Year
Location
Month
Day
Locaon
Month
Day
Location
Month
Day
Study:
Study:
Study:
Study:
,Yea
,
Have you treated yourelf? (Circle One) Yes No Explai:
Ar you tag any pain or other medicine due to the injur? (Cirle One)
Yes
Yea
Yea
No
If yes, give medicine name, dosage, frequency and effect:
Medicine:
Name Dose Frequency
Perceived Effect
None I Bad)
(Good I
Medicine:
Name
Dose
Frequency
Perceived Effect
(Good INone I Bad)
Medicine:
Name
Dose
Frequency
Perceived Effect
(Good / None I Bad)
Medicine:
Name
Dose
Frequency
Perceived Effec
(Good / None I Bad)
Medicine:
Name
Dose
Frequency
Perceived Effect
(Good I None I Bad)
Page 8
Were you ever denied medical treatment?
(Circle One)
Yes
No
If yes, explain why treatment was denied:____________________________________________
_____________________________________________________________________________________
mSTORY OF OTHR INJUS:
List injures that you have had from childhood unti now. Include date or year, whether work or auto related,
treatment and any remaiing problems or deformities:
1.
Injur:
Date:
Work related: (Circle One)
Yes
No
Auto òr motorcycle accident: (Cirle One)
Yes
No
Explai:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Treatment:
FuiI recover:
2.
(Circle One)
Injur:
Date:
Work related.: (Circle One)
Yes
No
Auto or motorcycle accident: (Circle One)
Yes
No
Explai:
Treatment:
Full recover: (Circle One)
3.
Injur:
Date:
Work related: (Circle One)
Yes
No
Auto or motorcycle accident: (Circle One)
Yes
No
Explain:
Treatment:
Full recover:
4.
(Cirle One)
Injur:
Work related: (Circle One)
Date:
Yes
No
Auto or motorcycle accident: (Circle One)
Yes
No
Explain:
Treatment:
Full recover: (Circle One)
5.
Injur:
Work related: (Circle One)
Date:
Yes
No
Auto or motorcycle accident: (Cirle One)
Yes
No
Explai:
Treatment:
Full recover: (Circle One)
Page 9
CURNT RELEVAN SYMTOMATOLOGY:
State what you can (or caot) do at ths tie:
How long can you sit before you must get up?
1.
a.
4.
5.
6.
No
How long ca you stand in one position?
2.
3.
Can you squat? (Circle One) Yes
hours
hours
a.
Can you bend to pick up something from the floor?
b.
Can you kneel?
How far can you walk?
Yes
(Circle One)
No
No
(Circle One) Yes
(Give distce)
a.
How much weight can you £I?
b.
Can you cniwl for ten feet? (Circle ODe)
lbs.
Yes
No
Climbin~
a.
Can you climb one flight of sta? (Circle One)
Yes
No
b.
Can you climb a ten foot ladder?
Yes
No
c.
Could you !: 25 feet?
(Cirle One)
(Circle One) Yes
No
Liftng
a
How many pounds can you lif from ground to wast?
b.
How many pounds could you li above vour shoulders?
c.
Can you twist while pulling? (Circle One)
d.
Can you push? (Cirle One)
Yes
No
e.
Can you pull? (Circle One)
Yes
No
Yes
lbs.
Ibs.
No
Hand Function
a.
Do you have trouble feeÜDe- with your fingers?
b.
Can you ir a haer?
c.
Can you hold a pen (pinch)?
d.
Can you operate hand or foot controls?
Page 10
(Circle One)
Yes
No
(Circle One)
Yes
No
(Cirle One)
Yes
No
(Circle One)
Yes
No
Patient describes daly pain as follows:
JOB llSTORY:
The patient lists the followig employers, by whom he was employed, staing with most recent employer:
1.
Employer:
From:
To:
From:
To:
From:
To:
From:
To:
From:
To:
Describe the job:
2.
Employer:
Describe the job:
3.
Employer:
Describe the job:
4.
Employer:
Descnbe the job:
5.
Employer:
Describe the job:
PAST MEDICALIDSTORY;
Chidhood Illesses: List any serous ilesses you had as a chid:
Adult Ilnesses: List any serious illnesses you had as an adult
Present medication taen regularly: List name(s) of medicines, the does (in mg) and number oftimes per day
the medicine is taen:
Medicine:
Name
Dose
Times per day
Name
Dose
Times per day
Name
Dose
Times per day
Medicine:
Medicine:
Page II
Medicine:
Name
Medicine:
Dose
Name Dose
Times per day
Times per day
Surgeries: List names of surgeries, where done and when:
Name of Surgery:
Location
Date
Location
Date
Location
Date
Location
Date
Location
Date
Name of Surgery:
Name of Surgery:
Name of Surgery:
Name of Surgery:
with hospita nae, àates of admssion
Hospitaliztions: List any time you have been an inpatient in a hospita
and dischage, and reason:
Name of
I
Hospita:
I
to
I
I
Dischage dae
to
I
I
Discharge date
Admsion dae
Name of
I
Hospita:
I
Admission dae
Name of
I
Hospita:
I
to
Admssion date
Name of
Hospita:
Name of
Hospita:
I
I
Admsion date
to
I
to
I
Admsion date
FAMY HISTORY: List any famly members who have the following diseases:
Cancer (location):
Diabetes:
Heart disease:
Hypertension:
Page 12
I
I
Dicharge dae
I
I
Discharge date
I
Discharge dat
REVIW OF SYSTEMS:
HENT: Have you had: (Circle any tht apply) Frequent, severe headaches? Nose bleeds? Hoarseness?
Eyes: Do you wear: Glasses: (Circle one) Yes No Contact lenses: (Circle one) Yes No
Any eye disease? (Circle any that apply) Glaucoma? Detached retina? Cataacts? Other:
Respiratory: Have you had: (Cirle any
that apply) Shortness of
breath? Chromc cough? Astha?
Bronchitis? Cough up blood? Pneumonia? Oter:
that apply) Hear attck? Angia? Aneursm?
Cardiac/Circulatory: Have you had: (Circle any
Thombophlebitis (blood clot in legs)?
that apply)
Endocrie: Do you have: (Circle any
Hepatic: Have you had: (Circle any that apply)
Diabetes?
Oter:
Thyroid disease? Other:
Jaundice? Viral hepatitis? Galbladder disease?
Other:
Gastrointestial:
Have you had: (Circle any that apply) Gastrc reflux? Ulcers? Colitis?
Other:
Have
you ever had colonoscopy? (Circle one) Yes No
Have you ever had black stools? (Circle oue) Yes No
Kidney/Bladder: Have you had: (Circle any tht apply) Nephrtis (kdney faiure)? Blood in ure?
Proste disease or cancer? Other:
Genital: Female:
Have you had: (Circle any that apply) Breast cancer? Breast lumps?
Blood from nipple? Abnormal pap smear? Cervcal or uterie cancer?
Fibroids? Oter:
Lat date of pelvic examtion:
!
mamogram (over 40 yeas):
La date of
!
!
Was the mamogr normal: (Circle one) Yes No
Male: Have you had: (Circle any that apply) Testicular tenderness? Other:
Las date of
Prostrte Specific Antigen (PSA) test:
!
(Black race: over 40 year, All Oters: over 50 year)
Was the PSA test normal: (Circle one)
Neurological: Have you had: (Circle any that apply) Seizues? Tremblig of
Other:
Page 13
Yes No
hands? DT's?
/
Psychological: Have you had: (Circle any that apply) Depression? Thoughts of sucide?
Oter:
NON-WORK ACTMTIES: Descnbe your non-work activities before the irur and now (including
recreation, sport, work around the house, drvig, etc.).
Before injury:
Currentl)':
SOCIA HISTORY:
Marital Statu:
Mared
(Circle one)
Single
Widowed
Chidren:
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Children:
Children:
Lives at home: (Circle one)
Yes
No
Lives at home: (Circle one)
Yes
No
(Circle one)
Yes
No
Lives at home: (Circle one)
Yes
No
Lives at home: (Circle one)
Yes
No
Lives at
Chidren:
Children:
Education: (Circle highest)
Divorced
home:
Eighth Grade
Tenth Grade
High School Diploma
G.E.D.
Some College
2 year college
4 yea college
Grduate degree
Other:
Page i 4
Certcations: List any professional certifcations
f
Certficate Name
Certificate Number
Date A warded
Certcate Name
Certficate Number
Date A warded
Cercate Name
Certficate Number
Date A warded
f
/
Habits:
Tobacco:
Do you smoke? (Circle One)
No
Yes
Packs per day
Alcohol:
Do you dr? (Circle One)
No
Yes
Amount
Did someone help you complete this questionnaire? (Circle One)
Name of person: (please print)
Signature of person:
Date form completed:
Page 15
Yes No
f
/
/