Patient History

Patient Name

Patient Age (required)

Patient Email address



Symptomatic Joint
Right HipLeft HipRight KneeLeft Knee

Who Referred You to See Us

Primary Care Doctor

Primary Doctor's Address/Phone

Any allergy to any medicine, metals, tape or Iodine? Please list all.

For what condition or symptoms are you being seen today?

When did the symptoms / condition first occur?

Is this a work injury?

History of this Condition: (please list in step by step dated from onset to present)
(If you have a problematic knee/hip replacement, please also list the name of the surgeon who implanted it, along with the hospital and the approximate date)

Pain Severity (Check all that best describe your condition)
None/IgnoreSlight, occasional, no compromise in activityMild, no effect on ordinary activity, pain after unusual activity, or occasional use of Aspirin or similar medicationModerate, tolerable, requires concessions in activity or occasional codeine or similar medicationSevere, requiring limitation of activityTotally disabling

Pain Location
Knee Patients: FrontInsideOutsideBack
Hip Patients: GroinSideButtockThigh

Gait (walking maximum distance)
Limp: NoneSlightModerateSevereUnable to walk
Support: NoneCane, long walksCane, full timeOne crutch2 Canes2 Crutches / walkerUnable to walk
Distance Walked: Unlimited6 blocks2-3 blocksIndoors onlyBed & Chair

Normally (one step with one leg, next step with other leg)Normally but with banister assistanceOne step at a timeNot able

Socks/Tie Shoes:
Right: With easeWith difficultyUnable
Left: With easeWith difficultyUnable

Any chair for as long as neededHigh chair for only a limited timeUnable to sit in any chair comfortably

Do you have night pain? yesno
Do you have pain while resting? yesno
Do you have pain on arising from sitting? yesno
Does your pain worsen after walking? yesno
Do you have a history of back pain or back surgery? yesno
Does your condition limit self-care / exercise / work? yesno

Dear Patient:

We are pleased that you have selected Dr. Mathews to evaluate and treat your knee or hip condition. In order to facilitate your care, we have the following office policies. Please read them closely and ask us to clarify any questions that you may have.

  1. Dr.Mathews is trained as a knee and hip surgeon. He has absolutely no training in pain management. Inasmuch, he does not and will not prescribe medications for treatment of chronic pain and in those patients who have no need for surgery. Ample pain medicine is provided in the hospital for patients after surgery and for 6 weeks after discharge. Patients with pain management problems will be referred to their primary care provider or to a pain management specialist.
  2. In those patients in whom a medication was prescribed, refills may be requested only during office hours: M-Th 9:00 am – 4:00pm and Friday 9:00am-12:00pm. Fondren Orthopedic Group policy is to not accept calls for pain medication refills after hours or on weekends.
  3. We respect the value of your time and will make effort to remain on schedule. You will find that Dr.Mathews will give you his attention during the visit. Due to the nature of a surgery practice, emergencies will on rare occasion cause us to be late or necessitate office visit rescheduling. In that event, we will make every attempt to contact you ahead of time.
  4. Disability forms are time-consuming for our staff and physician, and cannot be completed during clinic hours. Please allow several days for their completion. Be sure to complete your portion of the form before you leave it with us and provide a stamped, addressed envelope. Although we are happy to fill out forms for our patients, the time demands placed on our staff for such non-medical forms are significant. As a result, we must charge a $25 fee for each form. We regret any inconvenience this may cause.
  5. If you have any accounting or billing inquiries, please ask the insurance department when you reach our operator.

Please enter your name below to indicate that you have received and fully understand these policies.

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