As we hope you have experienced, there are many benefits to being a THPG patient, here are just a few:
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- Britton Preston
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1 Welcome Back to Texas Health Physicians Group As you may already know, our practice is one of the more than 250 Texas Health Physicians Group (THPG) practices located in 11 North Texas counties. THPG has more than 950 physicians, physician assistants, nurse practitioners and medical professionals dedicated to providing safe, quality care for all our patients. THPG s primary care and specialist network represents 59 medical specialties, in addition to offering sleep lab services, infusion services and diagnostic imaging. When you continue your care with a THPG primary care or specialty care provider, the registration information that you completed previously is stored in the Electronic Health Record THPG maintains. If you have any questions about the registration information you previously provided please let us know. Benefits of being a THPG patient As we hope you have experienced, there are many benefits to being a THPG patient, here are just a few: An improved patient experience with one-time registration to most (soon to be all) THPG locations Improved transition of care between all Texas Health providers Improved safety, better outcomes and increased efficiencies that can happen when all parts of the health care system work in close collaboration. As part of Texas Health Resources, THPG patients have access to over 29 hospital locations and more than 100 outpatient facilities, satellite emergency rooms, surgery centers, behavioral health facilities, fitness centers and imaging centers. Contact us Visit THPG online at to find a physician or practice. Thank you for the privilege of allowing us to continue to care for your health care needs If you have any questions or concerns, please ask one of our staff members.
2 FORT WORTH ORTHOPEDICS Disclosure regarding ancillary services/research programs Patient s Name: DOB: Ancillary Services Your physician may refer you to one or more Ancillary Services in connection with your medical care. An Ancillary Service is a service relating to your medical care or treatment. The following types of services are Ancillary Services: Magnetic Resonance Imaging (MRI) Bone Density Imaging Mammography Nuclear Imaging Ultrasound Laboratory Computer Tomography (CT) Durable Medical Equipment (DME) Positron Emission Tomography (PET) Echo Cardiograph X-Ray Sleep Therapy Infusion Therapy Audiology Your physician may have an economic interest in or a business relationship with the company or person who provides the Ancillary Services. You are not obligated to use the provider that your physician refers you to. You are free to use any provider you choose. Research Programs Your physician may ask if you would like to participate in a clinical trial or other research program. These programs may be sponsored by a drug company or may be part of a governmental research program. Your physician may be compensated for services rendered in connection with these programs. You are not obligated to participate in any research program and your permission will be obtained prior to your participating in a program your physician believes may be appropriate for you. Please feel free to ask your physician if you have any questions about a particular Ancillary Service or Research Program. Signature: Patient/Guardian if Minor Date: Fort Worth Orthopedics 6301 Harris Parkway, Suite 200 Fort Worth, TX (817) Rev
3 X-Ray Consent Form Date of Service: Patient name: DOB: I authorize the performance of a diagnostic x-ray(s) examination of myself which my provider may consider necessary or advisable in the course of my examination and treatment. (Signature of Patient or Legal Representative) (Witness) Date Date If Patient is a Minor I am the parent or legal representative of who is a minor, years of age. I authorize the performance of diagnostic x-ray(s) of this minor which the provider may consider necessary or advisable. Date (Signature of Guardian or Legal Representative) Consentimiento Para Radiografia Nombre Del Paciente: Fec. Nac. Autorizo la realizacion del examen diagnostic de rayos x de mi mismo, la cuál el medico considere necesaria o coveniente en el curso de mi examen y tratamiento. Fecha (Firma Del Paciente o Del Representate Legal) Fecha (Testigo) Paciente Menor De Edad Yo soy el padre/representante legal de que tiene la edad de, años. Autorizo la realizacion del examen diagnostic de rayos x del menor de edad, la cuál el medico considere necesaria o conveniente. Fecha (Firma Del Paciente o Del Representate Legal)
4 Pregnancy Questionnaire Your provider has ordered an X-Ray examination. To prevent radiation of an unborn child we request that you answer the following questions: Any chance of Pregnancy? Yes No First day of last menstrual cycle Please check any of the following that apply? Birth Control/IUD Yes No Tubal Ligation Yes No Menopause Yes No Hysterectomy Yes No Vasectomy Yes No Other Date (Signature of Patient or Legal Representative) Cuestionario De Embarazo El doctor a ordenado una examinacion de radiografias. Para evitar radiación en un bebe no nacido, se require que conteste estas preguntas: Hay posibilidad de embarazo? Si No Cuál fue el primer dia de su ultimo periodo? Por favor marque todos los que sean pertinentes? Pastillas Anticonceptivas/IUD Si No Ligadura de trompas Si No Menopausia Si No Histerectomia Si No Vasectomia Si No Otro Fecha (Firma Del Paciente o Del Representate Legal)
5 Fort Worth Orthopedics Medical History Part 1 Name: Age: DOB: Primary care doctor: Who referred you? ChiefCom plaint: When did the problem begin/surgery date: Which side: Right / Left How did the pain begin: Does it wake you at night? Yes / No What makes the pain worse: What makes the pain better: How would you rate your pain between 1 and 10, with 10 being the worse pain you have ever experienced: Are you experiencing any of the following? (circle) Fever Chills Weakness Leg swelling Tingling Sensory change Other: Have you had any (circle): Xrays MRI CT scan BoneScan EMG Mylelogram Other: Have you had Physical Therapy: Yes / No Please list all medications, vitamins, OTC pain relievers, or any other substance taken orally on a regular basis. Drug,T apeordyea lergies: M edicalhistory: (continue on back if needed) S urgicalhistory: Fam ily History:Does anyone in your family have a history of: Please list family member(s) Heart disease Diabetes Arthritis Stroke Kidney trouble Muscular disease Mental illness Substance abuse A reyou rightorlefthanded? Left / Right Fem ales: Is there any possibility you are pregnant? Yes / No S ocialhistory:do you smoke? (please circle) Yes / Former smoker / No, never smoked / If yes, how much? W orkrelatedinjury: Worker s Compensation? Yes / No Isthereanattorney involved? Yes / No Signature: Patient/Guardian if Minor Date: S T U DEN T A T HL ET ES O N L Y Name of School you attend: May we provide your athletic trainer and their associates with your health information? Yes No If yes, Name of Trainer Phone # Fort Worth Orthopedics 6301 Harris Parkway, Suite 200 Fort Worth, TX (817) Rev
6 Fort Worth Orthopedics Me dicalhistory Page 2 Name: Age: DOB: (Please circle) 1. Do you have a medical history of blood clots? Yes / N o If yes, please explain: 2. Family history of blood clots? Yes / N o If yes, please explain: 3. Do you have a medical history of MRSA or antibiotic resistance infection? Yes / N o If yes, please explain: Fem ales: 1. Birth control medication(s) and type: 2. Have you taken oral contraceptives within the past 3 months? Yes / N o 3. Hormone replacements medication(s): Signature: Patient/Guardian if Minor Date: Fort Worth Orthopedics 6301 Harris Parkway, Suite 200 Fort Worth, TX (817) Rev. 6/19/2018
Initial Pain Management Patient Questionnaire
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(FIRST) (MIDDLE) (LAST) STREET: CITY: STATE: ZIP CODE:
PATIENT INFORMATION EMAIL: MARITAL STATUS: [ ]MARRIED [ ]SINGLE [ ]DIVORCED [ ]WIDOWED NAME: (FIRST) (MIDDLE) (LAST) STREET: CITY: STATE: ZIP CODE: DOB: PHONE: [ ]Home [ ]Work [ ]Cell PHONE: [ ]Home [
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Workers Compensation Intake Form File Number (Office Use) Patient Information: Today s Date Home Phone Name Cell Phone I prefer to be called Preferred Contact Home Cell Email Social Security No. Date of
Accompanied by Relationship MEDICAL BACKGROUND INFORMATION. Please name the professionals that you have seen for this condition:
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Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
PATIENT DEMOGRAPHICS: Patient Name: First MI Last Preferred Name DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code: Home Phone: _( ) Marital Status: Married Single Divorced Widowed Cell Phone:
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Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
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*If the reason for your visit is due to a worker s compensation injury or an automobile accident, please inform the front desk immediately. PERSONAL INFORMATION of Birth Age (Last) (First) (M.I.) Address
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Date Name / / last first middle initial Personal Health # - Male Female Home Address City Postal Code Home Telephone # Business Telephone # Cell # E-Mail Address Best way to contact you: Home # Work #
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SPINE PROGRAM NEW PATIENT FORM
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PATIENT INFORMATION FORM
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Employed? Yes No Employer Name. Occupation. Problem Onset Frequency Severity E.g. Headaches June times per week Mild / Moderate / Severe
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Today s Date: What are your health goals? Symptom relief and preventing its return 100% optimum health and wellbeing on every level available to me
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