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- Dr. Hasan Syed Md
- Bryan Shane Penalosa
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New Patient Form

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PATIENT'S INFORMATION

ORTHOPEDIC SURGERY NEW PATIENT ENCOUNTER FORM

(fill out what applies to you or that you can easily recall and leave rest blank)

Reason for Visit | Primary Complaint/Condition:

Patient’s First Name:

Patient Last Name:

Age:

Gender

Male

Female

How did your injury occur or what do you think started your problem?

What date did this issue start? Approximate time of start of symptoms is okay.

What makes the problem worse?

What makes the problem better?

Number of cortisone injections (if yes, how many, approximately when and by whom)?

#2

#3

Prior surgery to this area?

Physical therapy for this issue (if so, when)?

Have to you tried NSAIDs (over- the counter or prescription alleve, motrin, ibuprofen, meloxicam, diclofenac gel, etc/?

Any use of braces or supports?

Tried weight loss?

Name 1 or 2 things you cannot do because of this issue:

Relevant Medical History

Previous Surgeries:

Yes

No

Diabetes:

Yes

No

Allergies:

Heart Attack:

Yes

No

Stroke:

Yes

No

Smoking:

Yes

No

Pain Assessment

Intensity of pain (on a scale of 0 to 10)

Normal level of pain in this area:

Level of pain when symptoms are at their worst:

Diagnostic Tests (have you had these tests for this issue/injury in the past 4 years – only list the recent ):

X-rays – if yes when approximately and location:

MRI – if yes when approximately and location:

CT Scan – if yes when approximately and location:

EMG | Nerve conduction study – if yes when approximately and location:

Other (please specify):

What diagnosis have you been given before?

Additional Information:

Name of primary care provider (and fax number if known)

Name of referring provider (if different from above and fax number if known)

Your Cell phone:

Your Email:

Enter Email Confirm Email

File

Max. file size: 2 GB.

909-315-6515 (M-F 8 am – 4 pm, no live reception Tues 11:30 am-1:30 pm) Fax: 909-315-6525

hasan.syed.md@outlook.com

25915 Barton Road, Suite 203, Loma Linda, CA 92354

5450 Jefferson Avenue, Suite 2, Chino, CA 91710

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