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),

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. ______________________________________________________________


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


Quelle est cette artere

Quelle est cette artère issue de la carotide commune ? Monsieur B., âgé de 55 ans, ayant pour antécédents une rectocolite hémorragique, un ex-tabagisme à 34 PA arrêté depuis 1 an, une hypertension artérielle (HTA) traitée par amlodipine et une dyslipidémie mixte traitée par fénofibrate, a été hospitalisé en novembre 2009 pour un 3e épisode de pancréatite aiguë d’ori


Por fin, nos toca a nosotros de dar gracias. Wir danken Ihnen und Euch für Ihr und Euer Gracias y Ustedes y a vosotros de haber venido Wir danken allen, die nicht kommen können und Extendemos este agradecimiento a todos que no han podido venir pero que están con nosotros en zu Hause im Herzen bei uns sind und für uns Wir danken für alle guten, liebevollen und Damos gracias por todas l

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