Gikk rotator cuff surgery protocol

TODAY’S DATE:_________

PATIENT NAME: _____________________DATE OF BIRTH: _______________ AGE: _____

HOME PHONE #: _______________ CELL PHONE #:_____________

1). Please explain what your problem is and what your goals and expectations are:
2). Are you interested in a surgical procedure or non-surgical procedure?

3). If you are here for knee pain check where you have pain:
___medial (big toe side), ___lateral (little toe side), ___anterior compartment (knee cap),
____generalized.

4). If you are here for hip pain check where you have pain: ___groin,___ outer hip area,

___buttock ,___anterior thigh, ___ knee ,___ anterior leg

5). How long have you had pain? ___________

6). How many blocks can you walk comfortably?

___Less than 1 block, ___1-2 blocks, ___3-6 blocks, ____Over 6 blocks

7). Please mark the activities that bother you: ___walking, ___getting out of a chair,

____doing stairs,___trouble sleeping,___trouble getting dressed

8). Do you have: ___swelling, ___stiffness, ___joint locks, __giving out,
___don’t trust your extremity to hold you, ___trouble getting dressed,
__trouble sleeping


9). Do you use a cane? ____

Do you use a walker? ____

10). Are you on any blood thinners? Such as: Plavix, Coumadin, Xarelto, Pradaxa, Pletal,

or Aggrenox.

11). Are you on any rheumatoid drugs? Such as: Methotrexate, Humira, Remicade, or

12). Are you on anything for pain? ________________________________________

13). If you have cortisone when was your last injection? _________________________

14). If you have had visco supplementation (“chicken shots”) when was your last shot____

15). List any surgery on your hip or knee. Date of surgery and where surgery was

performed. ______________________________________________________________

GENERAL MEDICAL QUESTIONS

1). Have you seen your dentist in the last six months? YES - NO

2). Circle any of the following risk factors you might have for your heart:

Angina – requiring taking nitroglycerin Vascular Disease – such as stroke

Heart Attack Hypertension

Diabetes High Cholesterol

Smoking Positive Family History of Heart Attack
(mother, father, or siblings)

Obesity Sedentary Activity
(Walking less than 1-2 blocks at a time)

3). Do you have a history of a cardiac bypass, coronary angioplasty? __________

4). Do you have a history of a pulmonary embolism, (blood clot in your lung), DVT,

(phlebitis in your leg)______

5). Have you ever had a bleeding ulcer? YES - NO

6). Do you have a history of sleep apnea? YES - NO

If so, mark risk factors you may have: ___Snoring, ___obesity, ___ hypertension,

___excessive tiredness during the day, ____getting up at night, ____ observed apneas,

___congestive heart failure, ____coronary artery disease, ____atrial fibrillation,

___ 17” neck male,___16” neck female

Source: http://www.midwesthipandknee.com/documents/newpatientdatasheetforwebsite.pdf