PATIENT INFORMATION SHEET Welcome to Cornerstone Orthopedics!

Transcription

1 PATIENT INFORMATION SHEET Welcome to Cornerstone Orthopedics! This form must be filled out completely to the best of your knowledge I. Patient Information Last Name: First Name: Middle Initial: Social Security #: - - Birth Date (Month/Day/Year): / / Sex: F M (Circle One) Address: Apt #: City: State: Zip: / Home phone: ( ) - Work phone: ( ) - ext.: Address: Cell phone: ( ) - Occupation: Employer: Employer Phone Number: ( ) - Emergency Contact Name: Phone Number: ( ) - Preferred Language: Race: Please check one: Native American Indian Asian Black/African American White/Caucasian Other More than one Choose not to report Ethnicity: Please check one: Hispanic or Latino Non-Hispanic Choose not to report II. Today s Visit Reason for visit: Date of Injury/Onset of Symptoms: How were you referred to us?: Referring Physician: Phone: Friend or Family Recommendation Previous experience at Cornerstone Cornerstone website Insurance List/Website Seminar by Cornerstone please specify Other: Primary Care Physician (PCP): PCP s Phone Number: ( ) - III. Insurance Information Primary Insurance: Secondary Insurance: Is your injury work or auto related? If no, continue to section IV. If yes, (Circle One) Workman s Comp Auto- State Accident Occurred Claim #: Date of Injury Adjuster Name: Adjuster Phone #: ( ) - ext.: Workerman s Comp Physician: Phone # ( ) -

2 IV. PRIMARY Policy Holder (Guarantor) Information (For insurance billing purposes, we require the name, date of birth, address if different than the patient and employer name and phone number of the person who is considered the insured. This person is not always the patient and could be a spouse, parent or another person). Guarantor Last Name: First Name: Middle Initial: Guarantor Sex: F M (Circle One) Relationship to patient: Address (if different from patient): Apt #: City: State: Zip: Guarantor Phone Number: ( ) - Guarantor Date of Birth: / / Guarantor Social Security # : - - Guarantor Employer Name: Employer Phone Number: ( ) - V. SECONDARY Policy Holder (Guarantor) If Applicable (For insurance billing purposes, we require the name, date of birth, address if different than the patient and employer name and phone number of the person who is considered the insured. This person is not always the patient and could be a spouse, parent or another person). Guarantor Last Name: First Name: Middle Initial: Guarantor Sex: F M (Circle One) Relationship to patient: Address (if different from patient): Apt #: City: State: Zip: Guarantor Phone Number: ( ) - Guarantor Date of Birth: / / Guarantor Social Security #: - - Guarantor Employer Name: Employer Phone Number: ( ) - Authorization to Pay Benefits/Release Information I hereby authorize payment directly to the Physician of the surgical and/or medical benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay for all non-covered services. I also hereby authorize the Physician to release any information acquired in the course of my treatment necessary to process insurance claims. Print Patient Name: Date of Birth: Signature: (If patient is under 18, the parent or guardian must sign) Today s Date:

3 Cornerstone Orthopedics & Sports Medicine, P.C Patient Name: Age: DOB: / / Today s Date: / / Did a doctor refer you to Cornerstone? If so, Doctor/Provider name: Preferred Pharmacy: (i.e.: Walgreens 120 th /Sheridan) City: Tobacco Use? Y N If yes, Type? How much per day? How many years? Have you tried to quit Y N If you are a former tobacco user, what year did you quit? Do you drink Alcohol? Y N Type: Amount per week: Height: Weight: Current Medications: Medications cont d Allergies & Reaction: (Drug / Latex / Nickel) No Allergies Reason for today s visit (briefly describe): Circle the following area that we will be evaluating today: (Circle Left or Right where applicable) L R Shoulder L R Arm L R Elbow L R Forearm L R Fingers L R Wrist L R Hand L R Hip L R Thigh L R Toes L R Knee L R Leg Pain Scale: (please rate the pain/discomfort on scale of 1 to 10 with 10 being worst) /10 L R Ankle L R Foot Neck/Cervical Spine Upper Back/Thoracic Spine Low Back/Lumbar Spine DESCRIBE YOUR INJURY/ACCIDENT Activity (e.g. walking) Place: (e.g. park) What Happened (e.g. fell down steps, tripped) STATUS Unchanged Improving Fluctuating Stable Worse Other PAIN QUALITY CONTEXT Aching Sharp No Injury Date of Onset Burning Throbbing Injury-- Date of Injury Dull Sports Injury-- Other Motor Vehicle Accident AGGRAVATED BY Nothing RELIEVED BY Nothing Bending Lifting Sitting Brace/Splint Ice Pain/Rx Meds Climbing Stairs Movement Standing Elevation Injection Mobility Descending stairs Pushing Walking Exercise Massage OTC Meds ASSOCIATED SYMPTOMS Bruising Locking Swelling Decreased Mobility Night Pain Tingling Joint Instability Numbness Tenderness Limping Popping Weakness Review of Systems (Please check all that currently apply) All Systems Normal CONSTITUTIONAL CARDIOVASCULAR INTEGUMENTARY METABOLIC/ENDOCRINE Fatigue Chest pain Rash Cold Intolerant Fever Discoloration--Cyanosis Heat Intolerant Night sweats Irregular heartbeat/palpitations NEUROLOGICAL PSYCHIATRIC GASTROINTESTINAL Difficulty walking Anxiety HEAD/EAR/NOSE/THROAT Constipation Dizziness Depression Headache Diarrhea HEMATOLOGIC Vision loss Vomiting MUSCULOSKELETAL Bleeding GENITOURINARY Other than today s reason for Bruising RESPIRATORY Painful urination--dysuria visit. Please explain: IMMUNOLOGICAL Cough Blood in urine--hematuria Environmental Allergies Difficulty breathing--dyspnea Incontinence Food Allergies Rev. 09/15

4 Print Patient Name: DOB: Past Medical History (Please check all that apply or list below) No Medical History AIDS/HIV Coronary artery disease Hypertension Peptic ulcer disease Alcoholism Crohn s disease Inflammatory Bowel disease Psoriasis Alzheimer s Degenerative Joint Disease Juvenile Rheumatoid Arthritis PVD-peripheral vascular disease Anemia Depression Kidney disease Renal disease Angina chest pain Diabetes Liver disease Rheumatoid Arthritis Arthritis Drug Abuse Lyme Disease Scoliosis Asthma DVT Blood Clots Migraine headaches Seizure disorder Atrial fibrillation Fibromyalgia Multiple Sclerosis Sleep Apnea Benign enlarged prostate Gall bladder disease Myocardial Infarction SLE Systemic lupus Cancer specify: GERD Obesity Spinal Stenosis CVA-stroke Gout Osteoarthritis Spondyloarthropathy Congestive heart failure Hepatitis Osteoporosis Thyroid disease COPD High Cholesterol Parkinson s Disease Valvular disease Other Medical History: Past Surgical History (Please check all that apply and indicate year of surgery or list below) No Surgical History Year Year Year Year ACL Surgery Back surgery Hernia repair Rotator cuff repair Angioplasty CABG coronary artery bypass Hip Arthroplasty Small bowel resection Angio w/ stent Cardiac valve Hip replacement Thyroidectomy replacement Appendectomy Carpal tunnel release Knee replacement Tonsillectomy Arthroscopy ankle Cataract extraction Laminectomy Gender Specific: Arthroscopy elbow Cholecystectomy LASIK Cesarean section Arthroscopy hip Colectomy Meniscus surgery Hysterectomy Arthroscopy knee Colostomy Muscle biopsy Mastectomy Arthroscopy wrist Discectomy ORIF fracture Prostate surgery fixation Arthroscopy shoulder Gastric bypass Pacemaker Urological surgery Other Surgical History: Family History Mother Father Brother (s) Sister (s) Other Pertinent Family History: Living Deceased Age Health Conditions (list any conditions, i.e., Past Medical History section) Social History Hand Dominance: (Circle one) Right / Left / Both Marital Status: Single / Married / Divorced / Separated / Widowed / Co-habitation Activity Level: Sedentary / Moderate / Vigorous / Competitive Athlete Type(s) of Exercise: Exercise Frequency: Hours/week: Hobbies Occupation: Rev. 09/15

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12 Patient Disclosure: Consulting Agreements with Orthopaedic Companies and Ownership Positions Dear Patient: Welcome to Cornerstone Orthopaedics and Sports Medicine! As a new patient we want to provide you with some information regarding Dr. Daniel Ocel s consulting agreements with orthopaedic companies, and other financial relationships pertaining to your orthopaedic care. Dr. Ocel has been active in his career with research and development of new implants and improved surgical instruments and techniques. Dr. Ocel has given instructional lectures on surgical techniques for other doctors and medical personnel. Dr. Ocel is also a paid consultant for Ossur Americas. This is a global prosthetic and bracing company for which he provides recommendations for new development of foot and ankle bracing. We want to assure you that the selection of which product to use in your care and the care of all of our patients is based only on what is best for the patient, not on which company makes the product. In addition, Dr. Ocel has an ownership interest in Flatirons Surgery Center, LLC. Dr. Ocel is a board certified orthopaedic surgeon and a member of the American Academy of Orthopaedic Surgeons, (AAOS) which holds its members to extremely high ethical standards to ensure that even the appearance of a conflict of interest does not jeopardize the trust that patients place in our doctors. AAOS has adopted Standards of Professionalism that require orthopaedic surgeon members to identify and disclose potential conflicts of interest to their patients, the public, and colleagues. These Standards also clearly articulate how and under what circumstances AAOS members may work with and be compensated by industry, as well as the penalties for failure to comply. You can learn more about these Standards of Professionalism at the AAOS website: It is important to our office that you are aware of these relationships with implant manufacturers, that our office puts the interests of patients first, and that we are available to answer any questions that you may have. Patient Signature Date

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