DEGENERATIVE JOINT DISEASE (ARTHRITIS) REPORT

PATIENT:_________________________________________________

SOCIAL SECURITY #:_______________________________________

D.O.B. :____________________________________________________

TO THE DOCTOR: Please complete the following report attaching copies of lab results for each condition. Please use the back of the form if additional space is needed.

Does this patient suffer from any arthritic impairment or disease?

_______Yes _______No

If yes,

A. What is the current diagnosis?

B. On what date was the diagnoses first made? _______________

C. What is the date of onset, if different? _________________

D. How long have you been treating the condition? _____________

E. What is the most recent date of examination? _______________

F. What was the patient's height ________ weight _________ at that time?

If possible, state the date of onset of disease in each joint (for example: left knee 8/82)":

Please describe any structural changes, i.e., structural deformity, bone destruction or bone hypertrophy:

Clinical abnormalities:

(A) Atrophy; if present, cite affected joint(s) with appropriate comparative measurements:

(B) Describe any local inflammatory or systemic signs:

Please list any obtained lab data:

Test	Results	Date	Normal	Abnormal	Antinucle	Antibodies
Sedimentation rate	_______	_______	_________	________	________	_________
Latex fixation	_______	_______	_________	________	________	_________
Uric acid	_______	_______	_________	________	________	_________
Serology (Rheun, factor)	_______	_______	_________	________	________	_________
Synovial fluid aspirate analysis	_______	_______	_________	________	________	_________
C-reactive protein	_______	_______	_________	________	________	_________
Other	_______	_______	_________	________	________	_________

Functional Abnormalities:

OVERALL RANGE OF MOTION (ROM)

The normal range is marked below in degrees, record patient's actual range next to normal range. Also record the presence of pain, and the condition of the joint, using the legend provided for joint condition.

Joint Condition
1/ PVMS = Paravertebral Muscle Spasm
2/ PMN = Periarticular Muscle Wasting
3/ T = Tenderness
4/ W = Warmth
5/ R = Redness
6/ S = Swelling
Presence Joint

		ROM	Presence of Pain Yes/No	Joint Condition
SPINE	Lumbosacral flexion 90___
	Lumosacral extension 20___
	Cervical flexion 30___
	Cervical extension 300___
HIP	Right flexion 100___
	Left flexion 1000___
	Right extension 30___
	Right rotation 40/40___
	Left rotation 40/40___
KNEE	Right flexion 150___
	Right extension 180___
	Left flexion 150___
	Left extension 180___
SHOULDER	Right abduction 150___
	Left abduction 150___
ELBOW	Right flexion 150___
	Left flexion 150___
	Right extension 180___
	Left extension 180___
WRIST	Right flexion 70___
	Left flexion 70___
	Right dorsal 70___
	Left dorsal 70___

DEXTERITY		FIST		GR1P
		Abnormal	Normal	Abnormal	Normal
HAND	Right Gross	______	______	______	______
	Right Fine	______	______	______	______
	Left Gross	______	______	______	______
	Left Fine	______	______	______	______
7.	Have any surgical procedures been performed? (please describe):
8.	Straight Leg Testing Results (Negative or Positive and if positive at what degree):
9.	Ambulation: Normal _____ Cane ____ Crutch _____ Walker _____
	If assistance was prescribed, as of what date? ___________________
10.	Has patient complained of any joint pain?
	(A) Please describe joints involved:
	(B) Is there any inflammation, swelling, or redness of each involved joint?
	(C) Has condition lasted for more than 3 months despite therapy for each joint? (Please describe)
	(D) Is condition expected to last for more than 12 months (please specify which joints)?
	(E) Does patient have signs, or symptoms of pain not corroborated by clinical findings? (Please describe)
	(F) Describe treatment prescribed:
	(G) Patient's response to treatment:
11. Please describe x-ray (or other radiologic) findings for involved joints and/or attach copy with results.
12. Medications prescribed? Yes _____ No _____ If yes, what are the medications and dosage?
13. Is the patient suffering from side effects from the medications? If so, please specify.
14. Any other comments or observations:

Date:	________________
Physician's signature and title:	_______________________________________
PLEASE PRINT: Name:	_______________________________________
Specialty:	_______________________________________
Address:	_______________________________________
Telephone:	_______________________________________

Law Office Of:
Jerrold S. Zivic
850 W. Jackson Blvd.
Suite 405
Chicago, IL 60607
800-400-4357

DEGENERATIVE JOINT DISEASE(ARTHRITIS) REPORT

DEGENERATIVE JOINT DISEASE
(ARTHRITIS) REPORT