Dr. Branson Hip Appointment Form

Name*
First Last
Email
Phone*
Hip:
- Right Side
- Left Side
Problem Onset:
- Gradual
- Sudden Onset
- Result of an Injury
Onset Date:
MM slash DD slash YYYY
Symptoms:
- Loss of motion/Stiffness
- Difficulty putting on shoes/socks
- Low back pain
- Pain radiating below knee to foot
- Pain in groin/upper thigh
- Limp
- Unable to bear weight
- Limited ability to walk
- Night time pain
Check all the apply.
I've been told that I have:
- Hip arthritis on Xray/MRI
- Ruptured discs
- Prostate problems
- Avascular necrosis
- Kidney problems
Location of PAIN:
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Please select the numbers.
History:
Pain, Swelling, loss of motion, injury: Tell us what happened and what is going on in your own words:
Prior Problems:
- Hip Injury
- Rheumatoid Arthritis
- Osteoarthritis
- Fracture
- Back Problem
- Back Surgery
Check those that apply:
Prior Studies:
- Xray
- MRI
- CT scan
- Bone Scan
- Back xrays
- Back MRI or other study
Check studies you have had:
PLEASE BRING REPORTS AND DISC of studies with you to your appointment. Hospitals do not send us the images. Doctors will review the images and reports. If you do not bring the studies and reports, a complete evaluation of your knee may be delayed.
Prior Treatments
Surgery Date Operation Helped or did not help?
Physical Therapy Number of Weeks Help or did not help?
Injections Date Helped or did not help?
Pain Medications
List
Walker, Cane, Crutches Helped or did not help?
If you have prior surgeries, please bring copies of the operative note, records/reports with you to your appointment. If you have hardware or implants in your hip, please request a copy of the IMPLANT RECORD from the hospital where surgery was performed. The Implant record should include the Manufacturer and type of implant.
Other notes for doctor:
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Address:
311 Courthouse Rd
Princeton,WV2470

Phone:
(304) 425-9563

NOTICE OF NONDISCRIMINATION:
Orthopedic Center of the Virginias complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Orthopedic Center of the Virginias does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. ATTENTION: If you do not speak English, language assistance services, free of charge are available to you via Fluent Language Services 1-888-306-7726. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. 1-888-306-7726. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。1-888-306-7726.

Surgery	Date	Operation	Helped or did not help?

Physical Therapy	Number of Weeks	Help or did not help?

Injections	Date	Helped or did not help?

Walker, Cane, Crutches	Helped or did not help?

Dr. Branson Hip Appointment Form

Prior Treatments

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