No Patient has insurance thru SPOUSES EMPLOYER: Ph#( ) Insurance: ID#: Group#: Ph#( ) Spouses Name: Male Female Birth Date: / / First Middle Last

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Bernice Stokes
6 years ago
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1 WEST ORANGE ORTHOPAEDICS & SPORTS MEDICINE P.A. MIR (Age 0-17) ADULT (Age 18+) Patients Legal Name: Suffix (Jr., Sr., Etc) Male Female Age: Birth Date: / / Nick Name: Employed Full Time Part Time Retired Unemployed SS#: No Patient has insurance thru their EMPLOYER: Ph#( ) Insurance: ID#: Group#: Ph#( ) No Patient has insurance thru SPOUSES EMPLOYER: Ph#( ) Insurance: ID#: Group#: Ph#( ) Spouses Name: Male Female Birth Date: / / If the patient is under 18 a parent/guardian must complete the rest of this form and sign as responsible party Guardians Legal Name: Suffix (Jr., Sr., Etc) Male Female Age: Birth Date: / / Relation: Employed Full Time Part Time Retired Unemployed SS#: No Patient has Insurance thru MY EMPLOYER: Ph#( ) Insurance: ID#: Group#: Ph#( ) No Patient has Insurance thru OTHER PARENTS EMPLOYER: Ph#( ) Insurance: ID#: Group#: Ph#( ) Parents Name: Mother or Father Birth Date: / / Mailing Address: Street Or PO Box Apt# City County State Zip Physical Address: Street Apt# City County State Zip Primary Phone: ( ) Ext Home Cell Work 2ndary Phone: ( ) Ext Home Cell Work Fax#:( ) Who referred you to our office? *PCP ER INSURANCE OTHER My Insurance Has Assigned a *PCP? Yes, Doctor: Phone#: ( ) (Notes automatically sent) OR No but, I wish for my notes to be sent to doctor Ph#( ) No Patient has TRICARE due to: Dependent Reserve Military Retiree Tricare 4Life ID#: Insured: Rank: Relation: Birth Date: / / No Patient has MEDICARE due to a Physical Disability Mental Disability 65 or older ID#: No Patient is currently staying at a skilled nursing facility: Temporarily Permanently No Patient has MEDICAID due to: Physical Disability Mental Disability OTHER ID#: No Patient is enrolled in a MEDICARE or MEDICAID HMO product: & has followed referral guidelines No Patient has an Primary individual insurance policy that is their only Insurance Or is their Secondary Policy. Insurance: ID#: Group#: Phone#: ( ) No Patient is eligible for Vocational Rehabilitation. No Patient does not have any insurance coverage at this time. Were you injured at a place of employment? Were you injured in/by an automobile? Were you injured due to a liability? If to auto or liability are you seeking third party reimbursement? Employer at time of injury: Ph#( ) Work Comp Carrier: Ph#( ) Claim#: Adjuster: Ext: PIP/Auto Carrier: Ph#( ) Insured: Relation: DOB: / / Claim#: Adjuster: Ext: Attorney: Ph#( ) Patient or Guarantor Signature: Date:

2 ( Page 1 of 3) WEST ORANGE ORTHOPAEDICS & SPORTS MEDICINE P.A. This form is crucial to your exam, Please complete in its entirety. SOCIAL HISTORY Patient s Name: Age: Birth Date: Male Female Single Married Separated Divorced Widowed Left Handed Right Handed Caucasian African American Hispanic/Latino Other: Height: Weight: Avg. Blood Pressure: / Student Or Employed Occupation: Job Duties: Tobacco Use? Never Not Now Yes If Yes, Packs per day? Alcohol Use? Never Not Now Yes If Yes, Daily Once a week Occasionally Date of last physical: Doctor: Phone: CHIEF COMPLAINT NECK MID BACK CHEST/RIBS LOW BACK/PELVIS What part of the body are we seeing you for today? (We can only see you for what is authorized/referral) LEFT UPPER EXTREMITY -- SHOULDER UPPER ARM ELBOW LOWER ARM WRIST HAND FINGER (Thumb, 2, 3, 4, 5) RIGHT UPPER EXTREMITY -- SHOULDER UPPER ARM ELBOW LOWER ARM WRIST HAND FINGER (Thumb, 2, 3, 4, 5) LEFT LOWER EXTREMITY -- HIP UPPER LEG KNEE LOWER LEG ANKLE FOOT TOES (BIG, 2, 3, 4, 5) RIGHT LOWER EXTREMITY -- HIP UPPER LEG KNEE LOWER LEG ANKLE FOOT TOES (BIG, 2, 3, 4, 5) Pain scale (Circle) (1=No Pain/10=Severe) Pain type & associated symptoms: Stabbing Dull Burning Numbness Swelling Nausea Other: Is your pain related to an injury? Yes No If, you must provide a Date of Injury? / / Describe HOW & WHERE the injury took place: If T an injury how long have you had this pain? Days Weeks Months Years What makes it feel better? What makes if feel worse? Physicians who have treated you for this problem(first & LAST NAMES PLEASE) Phone Number Date Range From To What activities can you do? What activities can you T do? Type Of Treatment Received From This Physician Anti-Inflammatory Medication Pain Medication Physical Therapy Cortisone Injections Surgery Other: Anti-Inflammatory Medication Pain Medication Physical Therapy Cortisone Injections Surgery Other: Current PCP: Anti-Inflammatory Medication Pain Medication Physical Therapy Cortisone Injections Surgery Other: REVIEW OF SYMPTOMS Have you recently had? Check all that apply CONSTITUTIONAL Weight loss/gain Fatigue Fever Chills Night Sweats MUSCULOSKELETAL Joint pain Joint swelling Joint stiffness Weakness GENITOURINARY Incontinence Frequency of urine Urgency Retention GASTROINTESTINAL Nausea Vomiting Chronic diarrhea Bleeding problems NEUROLOGICAL Paralysis Loss of sensation ENDOCRINE Excessive Urination Heat/Cold Intolerable I HAVE REVIEWED THE ABOVE & HAVE T HAD ANY OF THESE SYMPTOMS HEAD/SE/THROAT Frequent headache Sore throat Infections CARDIOVASCULAR Ankle swelling Blood clots (legs/lungs) Varicose veins RESPIRATORY Shortness of breath Difficulty breathing Productive cough PSYCHIATRIC Depression Memory loss Inability to sleep SKIN/INTEGUMENTARY Rashes Clammy Skin Open wounds or sores HEMATOLOGIC Bruising Easy Bleeding I HAVE REVIEWED THE ABOVE & HAVE T HAD ANY OF THESE SYMPTOMS PAST HISTORY & HISTORY - Have you or a blood relative ever been diagnosed with any of the flowing illnesses? Check No Check No Arthritis Mitral Valve Prolapse Asthma Nervous Disorder Anemia Peptic Ulcer Site: Cancer Site: Phlebitis (Inflamed Vein) Colitis Rheumatic Fever Diabetes Rheumatoid Arthritis Epilepsy Skin Disease (Specify) Gall Bladder Disease Hypothyroidism Gout Hyperthyroidism Heart Disease Tuberculosis High Cholesterol Other: Hypertension (High BP) Other: Kidney Disease Back Injury (Previous) DATE: Malignant Hyperthermia Neck Injury (Previous) DATE:

3 ( Page 2 of 3) WEST ORANGE ORTHOPAEDICS & SPORTS MEDICINE P.A. This form is crucial to your exam, Please complete in its entirety. MEDICATIONS List all prescription, non-prescription medications and supplements NAME OF MEDICATION WHAT IS IT FOR? STRENGTH/DOSE FREQUENCY (HOW DO TAKE?) NE SEE ATTACHED LIST ALLERGIES LIST ALL MEDICATION AND FOOD ALLERGIES REACTION NAUSEA VOMITING, ITCHING, RASH, SWELLING, DIFFICULTY BREATHING LIST ALL MEDICATION AND FOOD ALLERGIES REACTION NAUSEA VOMITING, ITCHING, RASH, SWELLING, DIFFICULTY BREATHING Penicillin Latex Aspirin Milk Sulfa Codeine Morphine Iodine None See Attached List PREVIOUS SURGICAL PROCEDURES LIST ALL PREVIOUS SURGICAL PROCEDURES DATES LIST ALL PREVIOUS SURGICAL PROCEDURES DATES Heart Gall Bladder Vascular Prostate Appendix Thyroid Hernia Colon None See Attached List

4 ( Page 3 of 3) WEST ORANGE ORTHOPAEDICS & SPORTS MEDICINE P.A. This form is crucial to your exam, Please complete in its entirety. SUPER-CONFIDENTIAL INFORMATION INDICATE ALL CONDITIONS FOR WHICH HAVE RECEIVED TREATMENT Mental health conditions (depression, anxiety, etc.) Presently Past Problem PLEASE INITIAL THE CORRESPONDING CATEGORIES LISTED BELOW WHICH WILL AUTHORIZE WEST ORANGE ORTHOPAEDICS TO DISCLOSE THAT IFRMATION TO THIRD PARTIES FOR TREATMENT OR PAYMENT PURPOSES IN THE EVENT THAT IT IS REQUESTED BY SAID THIRD PARTIES OR REQUIRED BY LAW Substance abuse (alcohol, narcotics, etc.) Presently Past Problem Illegal drug use Presently Past Problem Hepatitis HIV/AIDS Sexually transmitted diseases (STD s) Pregnancy under the age of 18 Are you in HOSPICE? Are you PREGNANT or could you be pregnant? Beginning Date: If yes, due date: Hospice related Illness: Last Menstrual Cycle: Patient Signature: Date: Print Name: Guardian Signature: Date: Print Name: Reason patient/guardian is unable to sign & representative s relationship to patient or authority to sign on behalf of patient or guardian

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New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) New Patient Documentation Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( ) Age: Birthdate: E Email: Social: Sex: Male Female Height: Weight: