Dean Fochios, M.D. , Daniel Bowman, M.D.,
& FoxCare Orthopaedics
One FoxCare Drive, Suite 211
Oneonta, New York 13820(607) 432-2239

 

CHART #:

 

 

NAME: 

DATE OF BIRTH:       
 Male/Female ( circle)                                                                  ORTHOPAEDIC PATIENT INFORMATION

 

What is your injury or chief complaint?_______________________________________________________

Where did your injury occur (i.e. home, school, work)?_________________________________________

When did the injury occur (specific date)?____________________________________________________

Who referred you to this office?____________________________________________________________

 

Please check if you have had or have any of the following medical conditions:

□          Aids                             □          Diabetes                                □          Pacemaker    

□          Alcoholism                 □          Emphysema                           □          Prostrate

□          Anorexia                     □          Gout                                       □          Psychiatric care

□          Anxiety                       □          Hepatitis                                □          Rheumatoid arthritis

□          Asthma                       □          Heart disease                                    □          Stroke

□          Bleeding disorder    □          High blood pressure                        □          Suicide attempt

□          Breast lump               □          High cholesterol                   □          Thyroid problems

□          Cancer                       □          Kidney disease                     □          Tuberculosis

□          Cataracts                   □          Liver Disease                                    □          Ulcers

□          Depression                □          Migraine Headaches                        □          Ulcerative Colitis

 

ALLERGIES:

MEDICATIONS:

 

 

 

 

 

 

 

 

List all previous surgeries:

 

 

 

 

 

 

 

 

 

Social History:

□          Tobacco            □          Alcohol             □          Live Alone

 

Present occupation:________________________________________________________________________________

 

Family History:

 

Age

State of health

Age at death

Cause of death

Father

 

 

 

 

Mother

 

 

 

 

 

Patient Signature:___________________________________________________Date:_________________

 

Current weight:           _______          Current height:            _______         

Vital Signs:                  _______          _______          _______          _______          _______________________

                                    Pulse                Temp                BP                    Respiration        Signature, Nurse/MA

 

Review form, Provider Signature:_______________________________________Date:________________