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1 FELLOWSHIP TRAINED SURGICAL SUBSPECIALISTS ' o o t n Mn ½j# 1) n n 2 ryst 5n t#rv #n tyo n ) j 7p Yn # 8o Yn t 0#p j) #? #n t L n o jo y 7 o u j #r n Uj: o w 7p Yn # 7u r#ry 7p o rts V# Y Yn # zr) u? ) n ' r) t u r# C#) r 3)tY#n ts d s FLORIDA.. RTHOP1\EDI Ti= "I INST ITU 6##p Yn y o u ) tyv #r NON-SURGICAL SERVICES 3) Yn V) n ) #? #n t 0 ##n #r)tyv # V# Y Yn # P Yro p r) t Y P) r# 3 y s Y ) j z #r) p y L u p )tyo n ) j z #r) p y 4r#n t P) r# M v ) n # 5? ) Yn 2 o r½#rs k Po? p #n s) tyo n LOCATIONS Tjo o? Yn ) j# z #r) p y I JmR Tjo o? Yn ) j# Mv #r G) jr Y o d '. SSJOR Tr) n o n SsJ Ur Tr) n o n Tjv r Tr) n o n d '. SSJII Tro o ½s v Yjj# II ScS Po rt#z Tjv r 7u Yt# SsS Tro o ½sv Yj j#d '. SpRI S PYtru s 3) r½ RII c Bu n n 1wy r z)? p ) d '. SSRvJ, o rt z)? p ) I Ssvs, r z#j# o? 3½wy r z#? p j# z#rr) #d '. SSRSc, o rt ) j# z #r) p y SRI m V) ) ). n r z)? p ) d '. SSRI m 3) j? 1) r: o r SRpI S 4r7r 1w y r I O, r 3) j? 1) r: o rd '. SpRmp z Ys j#tt#r Ys : #Yn Yv #n to y o u Yn r# #r#n # to y o u r o Y # v Ys Yt ) n p o s two p #r)tyv # ojjo w Wu p v Ys Yts w Yt o u r jyn Y ) n u ryn y o u r o s p Yt) j st) y r V y ro j# Yn t Ys o?? u n Yty d ) s ) n L rt o p ) # Y 7u r#o n d ) s ) jw ) y s : ##n to p ro v Y # t # : #s t ) r# or? y p )ty#n ts Yn ) ty? #jy ) n # Y Y#n t? ) n n #r r Cu ryn y o u r o Y # v Ys Yt o r o s p Yt) j st) y d Mu s tyn z o? p s o n ) n, Y o j# 3jo #r? y 3 y s Y Y) n Ms s Ys t) n ts d ) n 5 w Yjj : # p ro v Y Yn y o u w Yt ) p p ro p ry) t#d # Y Y#n t ) n p #rs o n ) jyz # ) r#r 1) v Yn ) q u ) jy Y# p y s Y Y) n ) s s Ys t) n t o n o u r s t) ) n ojjo w Yn y o u r p ro r#s s Yo n w Yj# Yn t # o s p Yt) jd p ro v Y #s y o u w Yt o n tyn u Yty o ) r# ) n ) jjo w s? # to o #r? y #x p #rtys # ) n o u n s #jyn to o u r o t #r p )ty#n ts Yn n ## r Mu s tyn z o? p s o n ) n, Y o j# 3jo #r ) r# p ) rt o o u r? # Y ) j st) ) n ) s : ##n tr) Yn # Yn t # Y#j o L rt o p ) # Y s u r#ry r Ms ) n #x t#n s Yo n o? y s #j t #y ) r# ) : j# to? o n Yto r y o u r o s p Yt) j st) y ) n ) r#s s ) n y q u #s tyo n s o r o n #rn s Yn ) ty? #jy? ) n n #rr L n ) y s t ) t 5 o n o t s ## y o u d Mu s tyn i, Y o j# ) n 5 w Yj j Ys u s s y o u r ) s # t o ro u jy r M YtYo n ) jjy d 5 p #rs o n ) jjy s u p #rv Ys # t # ) r# p j) n s Y? p j#? #n t# ) n ) s s u r# t ) t t # Y #s t j#v #j o p ro #s s Yo n ) j #) jt ) r# Ys #jyv #r# r 5 y o u ) r# ) n #w p )ty#n t to s ##? # ) n 5 )? n o t #r# o n t ) t ) y d p j#) s # r#q u #s t to s ##? # o n y o u r ojjo w u p v Ys Ytr 2 # w Yjj try to? ) ½# t ) t ) p p #n w Yt o u t y o u ) s ½Yn d : u t Y w # )Yj to o t Ys p j#) s # n o ty y o u r s # u j#r lmis e RSSWJvSv #x t#n s Yo n g RJSS ) n ) v # Yt r# ty Y# r Ty w o r½yn ) s d ) t#)? d w # ) r# ) : j# to #jp? o r# p )ty#n ts Yn ) ty? #jy )s Yo n d #jy? Yn )t# t # n # #s s Yty to r#s # u j# p )ty#n t ) p p o Yn t? #n ts d ) n? o s t Y? p o rt) n tjy d p ro v Y # t # : #s t p )ty#n t ) r# p o s s Y: j#r z ) n ½ y o u r 7Yn #r#jy d 7o u t z)? p ) OsO, r C) j# V) : ry 1w y r z)? p ) d '. SSRsO 7u n PYty P#n t#r OJO Ur C#j 2 #: : Tjv r 7u n PYty P#n t#rd '. SSJcS 2 #s j#y P ) p #j vrjs Tru # Tr Co w n s 7u Yt# vsi 2 #s j#y P ) p #jd '. SSJpp Orthopedic Urgent Care 7o u t z)? p ) Mn t o n y ' r 5n )n t# 8rrd Mp p o Yn t? #n ts g mi SWOcmWOcOc B#n #r) j 5n or? ) tyo n g mi SWOcmWOcss 4r#n t P) r#g mi SW'. WL 0z1 L lmi SWSJRWcmpRe ww w r jo ry ) o rt o r o? 1 UM. z1 A. \JSF Jk1lth Academic Affiliate

2 Patient Name: DATE: DOB: MR#: ANTHONY INFANTE DO - PATIENT HISTORY PATIENT INFORMATION Primary Physician Information Family/Primary Physician: Family/Primary Physician address and phone#: Who referred you? Patient: Doctor: Friend: Advertising: Other: Marital Status: Handed: Height/Wei~ ht Occupation: D single, D right Height D married D left D divorced D both Weight D widowed Sex: Male Female Current Work Status: D employed D not working 0 retired D light duty Have you seen a doctor in the past for this problem or injury? If yes, who, when and where? In your own words, please describe how your injury occured? 8/6/2013 1

3 Patient Name: DOB: MEDICAL CONDITION HISTORY DATE: MR#: Medical Condition History: D NO MEDICAL PROBLEMS 0 Depression D Alcoholism 0 Gout D Anemia HIV D Anxiety Hypertension (High Blood Pressure) D Asthma Hypercholesterolemia (Elevated Cholesterol) D Arthritis -inflammatory Hypothyroidism (rheumatoid) D Arthritis - osteo, 0 Kidney Disease deaenerative D Bowel disease Liver Disorder (Cirrhosis, Hepatitis) D Cancer 0 Lung Disease (COPD, emphysema) D Cardiac Arrhythmia Osteomyelitis (Abnormal heart rate) D Congestive Heart Failure 0 Parkinson's D Coronary Artery Disease Ulcer Disease (Anainal Cerebrovascular Disease Other (Stroke) Diabetes Other Medical Condition: Have you ever had a blood clot? I Yes I!No Have you every had a blood transfusion? I Yes I!No 8/6/2013 2

4 Patient Name: DATE: DOB: MR#: SURGERY /PROCEDURES Arthroscopy Fracture Repair D right shoulder D left shoulder D right shoulder D left shoulder D right elbow D left elbow D right arm D left arm D right wrist/hand D left wrist/hand D right elbow D left elbow D right hip D left hip D right forearm D left forearm D right knee D left knee D right D left wrist/hand wrist/hand D right foot/ankle D left foot/ankle D right pelvis D left pelvis D right hip D left hip Joint Replacement Surgery D right femur D left femur (thlohl (thigh) D right shoulder D left shoulder D right knee D left knee D right elbow D left elbow D right D left tibia/fibula tibia/fibula D right wrist/hand D left wrist/hand D right D left foot/ankle foot/ankle D right hip D left hip D right knee D left knee Spine Surgery D right foot/ankle D left foot/ankle D Cervical I O I Thoracic I 0 I Lumbar Other Orthopedic Surgery Non Orthopedic Surgeries D abdominal surgery D hernlo repair D brain surgery D plastic surgery D cancer surgery sinus surgery D cardiothoracic surgery D tonsillectomy D eye surgery D urology surgeries D gallbladder surgery D vascular surgery D gynecologic surgery D other Other Surgeries 8/6/2013 3

5 Patient Name: DOB: SOCIAL HI STORY DATE: MR#: Current Level of Exercise: Employment: Education: D Full Time D Grade School D do not regularly exercise D Part Time D High School/ D once per week Equivalent D Retired D Some College D 3-5 times per week D Student D College Degree D daily D Unemployed D Graduate Degree D Disabled Alcohol: Tobacco: D Never use alcohol D I use chewing tobacco D Used to drink but stopped D I have never smoked tobacco D Rarely drink alcohol D I used to smoke tobacco (<1 /month) but stopped D Drink occasionally D I currently smoke less than ½ (1-4/monthl pack per day D Drink socially ( 1-2/week) D I currently smoke ½-1 pack a day D Drink frequently (3-5/week) D I currently smoke 1-2 packs a day D Drink daily ( 1 /day) D I currently smoke more than 2 packs a day Drue s: D Do not use drugs D cocaine D marijuana D other Other druas: 8/6/2013 4

6 Patient Name: DOB: FAMILY MEDICAL HISTORY DATE: MR#: Please check all diseases for which vou have a family history: D Arthritis, Rheumatoid (inflammatory) D Arthritis, Degenerative D Cancer - Breast D Cancer- Prostate D Cancer - Other D Dementia D Diabetes D Heart Disease D High Blood Pressure D High Cholesterol D Lung Disease D Stroke D Other Other diseases: 8/6/2013 5

7 Patient Name: DATE: DOB: MR#: MEDICATIONS AND ALLERGIES Are you currently taking any medications? I Yes I I No Patient Current Medications: Medication Name Dose For what purpose? Do you have any allergies? I Yes I I No Please list all allergies (includina iodine and contract dyes): Alleray Severity 1 Mild Moderate Severe 2 Mild Moderate Severe 3 Mild Moderate Severe 4 Mild Moderate Severe 5 Mild Moderate Severe 6 Mild Moderate Severe 7 Mild Moderate Severe 8/6/2013 6

8 Patient Name: DOB: REVIEW OF SYSTEMS DATE: MR#: General Eves ENT & Mouth Pulmonary (lunasl D none D none D none D none D recent weight gain D difficulty D difficulty seeina hearina D shortness of breath recent weight loss D Loss of D nose bleeds vision D dry cough D D appetite change D double D swallowing D productive cough vision difficulty (sputum) D difficulty sleeping D blurred D Sinus D bronchitis vision problems D Fevers D asthma D Problems walking (balance D sleep apnea problems, fallinal Night sweats D 8/6/2013 7

9 Patient Name: DOB Gastrointestinal Genltourinarv Musculoskeletal Hematopoletlc/L vmohatlc No issues No issues D No issues No issues heartburn/ burning on urination joint pain anemia inaestion difficulty frequency of joint deformity lymph node swallowina urination enlaraement stomach pains difficulty starting joint swelling or urine warmth frequent infections ulcers wetting pants or joint stiffness bed excessive bleeding nausea/ bloody urine muscle pain vomitina blood clots diarrhea sexual difficulties weakness hemorrhoids neck pain rectal bleeding back pain black bowel Skin Neurologic movements change in bowel No issues habits No issues Psychiatric constipation ecchymotic headaches No issues frequent laxative purulent drainage dizziness anxiety use (pus) jaundice or swollen hepatitis blackouts depression liver trouble Erythematous (red) numbness and difficulty sleeping tinalina gallbladder rash problems paralysis appetite changes itching convulsion/seizur confusion es easy coordination bruisina/bleedina trouble memory loss slow healing been seen by a psychiatrist Endocrine/Metabolic Cardiovascular No issues No issues leg cramps (when walking) diabetes high blood pressure fainting goiter chest pain coldness in hands and/or feet thyroid problem heart attack loss of hair on arms or legs sterility palpitations (irregular heart beat) abnormal color (blue, white, red) in hands or feet cholesterol / lipid heart failure other oroblem edema (leg swelling) DATE: MR#. 8/6/2013 8

10 Patient Name: DOB: DATE: MR#: GENERAL NEW PATIENT HISTORY CURRENT INJURY /PROBLEM What is the MAIN injury/problem you are seeing the doctor for today? IF UNLISTED CHOOSE THE CLOSEST. right shoulder left shoulder head right arm left arm neck right elbow left elbow chest right forearm left forearm midback right wrist/hand left wrist/hand low back right hip left hip Problems walking 0 right thigh left leg Weakness, numbness, tinglinq right knee left knee Other right calf left calf right foot/ankle left foot/ankle If more than one injury /problem, which is worse? SELECT ONLY ONE - IF UNLISTED CHOOSE THE CLOSEST. right shoulder left shoulder head right arm left arm neck right elbow left elbow chest right forearm left forearm midback right wrist/hand left wrist/hand low back right hip left hip Problems walking right thigh left thigh Weakness, numbness, tinglina right knee left knee Other right calf left calf right foot/ankle left foot/ankle Date lnlu / roblem be an APPROXIMATE IF UNSURE: Is vour oroblem a result of an injury /problem? Yes No 8/6/2013 9

11 Patient Name: DOB: DATE: MR#: Please describe your current problem. IF YOU ARE SEEING THE PROVIDER FOR MULTIPLE PROBLEMS, ANSWER FOR THE MOST SEVERE: New injury or problem (less than 6 weeks duration) Sub-acute problem (6 week- 3 months duration) Chronic problem (problem has been treated over time period of more than 3 months and never been restored to normal) Re-injury What caused your injury /problem? Fall Lifting Throwing Reaching Pulling Fighting Twisting Sports Collision/Contact D Other If the problem/injury is a result of an iniurv, where did it occur? at home at work via a motor vehicle accident D while exercising at a sport competition other Other cause of injury /problem: Other: Check any of the following that happened at the time of your iniurv /problern: Felt pain Had swelling Fracture I Bruising Heard popping Dislocation D Deformity Have you had surgery related to the problem you are being seen for today? Yes No 8/6/

12 Patient Name: DATE: DOB MR#. What conservative treatment have you had on or since your lnlurv/problern began? D Injection D Chiropractic care D Aspiration D Bracing D Physical Therapy D Heat D Exercise D Ice D Anti-inflammatory medication D Massage D Pain medication D Rest Date you began conservative treatment Have you received non-surgical Are you receiving or have you treatment for at least 3 months for this applied for worker compensation problem? concerning your problem/injury? D Yes D Yes D No D No Have you talked to a lawyer Is your problem the result of an concerning your problem/injury auto accident? D Yes D Yes D No D No PAIN o continuous/constant 4 D 5 D 6 D 7 D 8 D 9 D 10 D never occasionally D frequently What time of day is Check the words that best describe the character vour oain worst? of the oain vou are havlna today: morning D aching D nagging D shooting afternoon D burning D numb D tender evening D exhausting D throbbing D unbearable nighttime D gnawing D sharp all the time miserable D stabbing 8/6/

13 Patient Name: DATE: DOB: MR#: What makes your symptoms better? rest sittina sports/exercise medication standina brace/cane/crutch ice walkina sleeolno heat sauattinq D physical theraov lvina down stretchina iniection nothing in particular Other factor that makes the pain better: What makes your svmotoms worse? lying down D stooping/ pushing bendina sittina D liftina oullino stcndlno souottlno worklno walking stairs nothing in particular sports/ D reaching exercislno twisting/pivoting overhead activity activity in oenerol Other factor that makes the pain worse: 8/6/

14 Patient Name: DATE: DOB: MR#: Pharmacy Name PREFRERRED PHARMACY INFORMATION Pharmacy Street Address City, State, Zip If address unknown please provide crossroads Pharmacy Phone Number Everything I have answered is true and correct to the best of my knowledge. Patient Signature: Date: 8/6/