Sports Medicine Orthopedic Surgeon – Houston, TX Dr. David Lintner, M.D.

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)

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New Patient Questionnaire

Download the Questionnaire for New Patients in PDF format.

Please complete this form BEFORE your appointment.

Name*
PrefixFirstLastSuffix
Age
Email Address*
Best Daytime Phone*
Who is your primary care physician?
When did you last see him/her?
Body part injured?
Have you ever had any of the following (in the past)?
- Asthma
- Balance Problems
- Bladder or Urinary Infections
- Blood in Stools
- Blood Clots
- Cancer
- Chest Pain
- Chronic Bronchitis
- Cramping in Leg While Walking
- Colitis
- Deep Venous Thrombosis
- Diabetes
- Emphysema
- Fainting
- Frequent Bloody Noses or Bleeding Gums
- Gallstones
- Heart Attack
- Heart Murmur
- Heart Surgery
- High Blood Pressure
- High Cholesterol
- Joint Replacement
- Kidney Stones
- Osteoporosis
- Poor Circulation
- Recurrent Infections
- Shortness of Breath
- Slowly Healing Wounds
- Stomach Ulcer
- NORMAL. I've had none of the above.
Type of Cancer?
Review of Systems...
Do you currently have any of the following?
- Reaction of NSAID/anti-inflammatory medications (Advil, ibuprofen, Naproxen, Indocin, Celebrex, etc.)
- Fever or chills.
- Recent weight gain or recent weight loss.
- Changes in vision, sensitivity to light, blurred vision, double vision.
- Change in hearing, bloody noses, sore throat, cough.
- Shortness of breath, chest pain, wheezing, coughing of blood.
- Palpitations, light headedness, dizziness.
- Loss of appetite, weight loss, pain with swallowing, nausea, vomiting, abdominal pain or bloating, blood in your stools, diarrhea, constipation.
- Difficulty urinating, pain with urination, blood in your urine.
- Rashes, insect bites, new skin lesions.
- NORMAL. I've had none of the above.
What medications do you take?
Are you allergic to any medications?
- Yes
- No
To which medications are you allergic?
Do you smoke?
- Yes
- No
How many packs per day?
How much alcohol do you drink?
What surgeries have you had in the past?
eSignature
- I certify that I am the patient named above, and that all the responses contained in this form are accurate to the best of my knowledge.
- I certify that I am the parent or legal guardian of the patient named above, and that all the responses contained in this form are accurate to the best of my knowledge.
Name of Parent or Legal Guardian
PrefixFirstLastSuffix
Name
This field is for validation purposes and should be left unchanged.

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Dr. David Lintner

Dr. David Lintner specializes in arthroscopic surgery of the knee and shoulder and is active in teaching orthopedic surgeons the latest techniques. He also specializes in injuries to throwers’ shoulders and elbows, having written more than thirty scientific articles about ACL injuries, thrower’s injuries, and other sports medicine issues.

Read more about Dr. David Lintner

Pages in this Site

Orthopedic Sports Medicine Specialist
Dr. David Lintner
Our Staff
Sports Injuries
Surgery Information
Rehab Protocols
Appointments
Articles
Contact

Most Recent Articles

Dr. Lintner interviewed about faking of injuries in the NFL.
US News and World Report names Dr. Lintner to “The Best Doctors in America”
Radio Interview
How Texas is Striving to Make Football Safer
A Little Preparation Can Make for Safer Skiing

Orthopedic Links

American Association of Orthopedic Surgeons
DS2 Rehab Systems (The DS2 Platform)
Journal of the American Academy of Orthopaedic Surgeons
The American Orthopaedic Society For Sports Medicine

Rehabilitation

DS2 Rehab Systems (The DS2 Platform)

Sports Links

DS2 Rehab Systems (The DS2 Platform)
TSU Tigers

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)

©2003-2010 Dr. Lintner, MD. All Rights Reserved.

Dr. David Lintner is an orthopedic sports medicine specialist practicing in Houston, TX, as well as team doctor to many of the professional teams in the Houston area.

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