Welcome to our Practice! We appreciate you choosing us for you healthcare needs. Following are all forms necessary for your upcoming visit, including a personal history form for patients with musculoskeletal problems. These forms allow us to obtain as much information as possible to better evaluate and treat your problem. Please bring the completed forms with you on your appointment date. You need to arrive 30 minutes before the time of your appointment. Please bring all medications, your medical insurance card, and the names, addresses, and telephone numbers of all doctors involved in your care. If you are an established patient within this practice and have a change in insurance coverage, home address, employment, etc. you should arrive early in order to update this information with our front desk staff. We need the following information from your referring doctor: A referral number if you have HMO Insurance All recent laboratory reports X-ray films if you have had a recent x-ray and this is the reason you are being sent to see the Specialist, otherwise, the x-ray report All recent office notes from your referring doctor to let us know why you are being sent for the appointment Please arrange to pick up this information in advance from your physician s office and bring it with you at the time of the appointment. Our fax number is (804) 915-0036. You may request that this information be faxed to us; however, double check with your physician s office to make sure the requested information has been sent prior to your scheduled appointment. Additionally, we request that you kindly give us 24 hours notice if cancellation is necessary. Otherwise, you may be billed for the cost of the missed appointment. We may be contacted at (804) 346-1551. Thank you for your cooperation. Department of Rheumatology 7650 East Parham Road MOB II - Suite 304 Richmond, Virginia 23294
MEDICAL SPECIALISTS DIVISION REGISTRATION FORM PATIENT INFORMATION Name: Social Security#: First Middle Last Address: Suite/Apt. #: City: State: Zip Code: Home #: Work #: Cell #: May leave message at: Home Work Cell Email address: Gender: F M DOB: / / Marital Status: Preferred Language: (if other than English) Race/Ethnicity: American Indian Black/African American Hispanic/Latino Native Hawaiian White Asian Other Pharmacy Name and Address: Phone #: Primary Care Physician: Referred by: INSURANCE INFORMATION Primary Insurance Name and Address: Insured Name: First Middle Last Insured DOB: / / Insured ID and Group Number: / Relationship to Pt.: Self Spouse Child Secondary Insurance Name and Address: Insured Name: First Middle Last Insured DOB: / / Insured ID and Group Number: / Relationship to Pt.: Self Spouse Child EMERGENCY CONTACT Name: Relationship to Patient: First Middle Last Home #: Work #: Cell #: NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT Our Notice of Privacy Practices (available upon arrival to our office) provides information about how we may use and disclose protected health information (PHI) about you. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy. I have received* a copy of Virginia Physicians, Inc. s Notice of Privacy Practices. I understand that I may ask questions to the Medical Practice if I do not understand any information contained in the Notice of Privacy Practices. Patient Initials/Date *If you are completing this form prior to your scheduled appointment please note that the Notice of Privacy Practices will be made available to you upon arrival to our office.
E-PRESCRIBING MEDICATION HISTORY CONSENT I understand that Virginia Physicians, Inc. has implemented e-prescribing for its patients. I also understand that e-prescribing involves the ability for the practice to send prescriptions electronically to pharmacies, eliminating the need for a more timeconsuming, and sometimes more costly, approach to prescribing through paper, phone and fax. E-Prescriptions are fast, convenient, legible, secure, cost-effective and safe. The e-prescribing process also allows the health care provider to access critically important information about their patient s current and past medications from pharmacy benefit managers and community pharmacies. This information helps alert the provider to other potential medication issues with their patients and can improve safety and quality. I have been given an opportunity to ask questions about the e-prescribing process and have had those questions answered to my satisfaction. I hereby consent to the practice requesting and using my medication history from other health care providers or third party pharmacy benefit payors for treatment purposes in connection with the e-prescribing process. Patient Initials/Date FINANCIAL POLICY General Information: Payment in full is due at the time of service. We accept cash, check, American Express, Discover, MasterCard and Visa. Regarding Insurance: We accept most major insurance plans, but you are responsible for checking with your carrier to see if services at our office will be covered. We do not participate with any Medicaid plans. We may accept assignment of insurance benefits; however we do require that all co-payments be made at the time of service. The balance is your responsibility whether your insurance company pays or not. It is your responsibility to notify us of any changes in your policy information. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please be aware that some, and perhaps all, of the services provided may be non-covered and not considered reasonable and necessary under the Medicare Program and/or other medical plans. You will be responsible for these balances. Additionally, it is your responsibility to obtain and track referrals for your visits. Returned Checks: There will be a $25 returned check fee on all returned checks. In the event that a check is returned for insufficient funds, we reserve the right to call your bank to verify funds for any future checks that are presented for payment. Collection Fees : In the event that your account is turned over to a collection agency, you will be responsible for all collection costs including reasonable attorney s fees. Missed Appointments: Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the minimum rate of $25 per missed appointment. Please help us serve you better by keeping your scheduled appointments. Fees for Letters and Forms: Your physician will be happy to fill out any necessary form that you may need. Please be advised that due to the time required to dictate and complete letters and forms there will be a fee for this service. These costs are considered non-covered by insurance companies and will be your personal responsibility. I have read, understand and agree to this Financial Policy: Patient Initials/Date DISCLOSURES TO FAMILY MEMBERS AND FRIENDS Disclosures may be made to family and friends related to the patient s health or as needed for payment of health care services. We will only disclose information relevant to current treatment. I authorize Virginia Physicians, Inc. to disclose my health care information to: Name Phone Number Relationship Name Phone Number Relationship Name Phone Number Relationship Patient Signature (or Authorized Patient Representative) Date
Patient History Form Date of first appointment: / MONTH DA Y / YEAR Time of appointment: Birthplace: Name: Birthdate: / LAST FIRST MIDDLE INITIAL MAIDEN MONTH DAY / YEAR Address: STREET APT# Age: Sex: F M Telephone: Home ( ) CITY STATE ZIP Work ( ) MARITAL STATUS: Never Married Married Divorced Separated Widowed Spouse/Significant Other: Alive/Age Deceased/Age Major Illnesses EDUCATION (circle highest level attended): Grade School 7 8 9 10 11 12 College 1 2 3 4 Graduate School Occupation Number of hours worked/average per week Referred here by: (check one) Self Family Friend Doctor Other Health Professional Name of person making referral: The name of the physician providing your primary medical care: Do you have an orthopedic surgeon? Yes No If yes, Name: Describe briefly your present symptoms: Example: Please shade all the locations of your pain over the past week on the body figures and hands. Date symptoms began (approximate): Example Diagnosis: Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later) Please list the names of other practitioners you have seen for this problem: RHEUMATOLOGIC (ARTHRITIS) HISTORY At any time have you or a blood relative had any of the following? (check if yes ) Yourself Relative Name/Relationship Yourself Arthritis (unknown type) Osteoarthritis Gout Childhood arthritis Other arthritis conditions: Adapted from CLINHAQ, Wolfe F and Pincus T. Current Comment Listening to the patient A practical guide to self report questionnaires in clinical care. Arthritis Rheum. 1999;42 (9):1797-808. Used by permission. Lupus or SLE Rheumatoid Arthritis Ankylosing Spondylitis Osteoporosis Relative Name/Relationship
SYSTEMS REVIEW As you review the following list, please check any of those problems, which have significantly affected you. Date of last mammogram / / Date of last eye exam / / Date of last chest x ray / / Date of last Tuberculosis Test / / Date of last bone densitometry / / Constitutional Recent weight gain amount Recent weight loss amount Fatigue Weakness Fever Eyes Pain Redness Loss of vision Double or blurred vision Dryness Feels like something in eye Itching eyes Ears Nose Mouth Throat Ringing in ears Loss of hearing Nosebleeds Loss of smell Dryness in nose Runny nose Sore tongue Bleeding gums Sores in mouth Loss of taste Dryness of mouth Frequent sore throats Hoarseness Difficulty in swallowing Cardiovascular Pain in chest Irregular heart beat Sudden changes in heart beat High blood pressure Heart murmurs Respiratory Shortness of breath Difficulty in breathing at night Swollen legs or feet Cough Coughing of blood Wheezing (asthma) Gastrointestinal Nausea Vomiting of blood or coffee ground material Stomach pain relieved by food or milk Jaundice Increasing constipation Persistent diarrhea Blood in stools Black stools Heartburn Genitourinary Difficult urination Pain or burning on urination Blood in urine Cloudy, smoky urine Pus in urine Discharge from penis/vagina Getting up at night to pass urine Vaginal dryness Rash/ulcers Sexual difficulties Prostate trouble For Women Only: Age when periods began: Periods regular? Yes No How many days apart? Date of last period? / / / Date of last pap? / / Bleeding after menopause? Yes No Number of pregnancies? Number of miscarriages? Musculoskeletal Morning stiffness Lasting how long? Minutes Hours Joint pain Muscle weakness Muscle tenderness Joint swelling List joints affected in the last 6 mos. Integumentary (skin and/or breast) Easy bruising Redness Rash Hives Sun sensitive (sun allergy) Tightness Nodules/bumps Hair loss Color changes of hands or feet in the cold Neurological System Headaches Dizziness Fainting Muscle spasm Loss of consciousness Sensitivity or pain of hands and/or feet Memory loss Night sweats Psychiatric Excessive worries Anxiety Easily losing temper Depression Agitation Difficulty falling asleep Difficulty staying asleep Endocrine Excessive thirst Hematologic/Lymphatic Swollen glands Tender glands Anemia Bleeding tendency Transfusion/when Allergic/Immunologic Frequent sneezing Increased susceptibility to infection
SOCIAL HISTORY Do you drink caffeinated beverages? Cups/glasses per day? Do you smoke? Yes No Past How long ago? Do you drink alcohol? Yes No Number per week Has anyone ever told you to cut down on your drinking? Yes No Do you use drugs for reasons that are not medical? Yes No If yes, please list: Do you exercise regularly? Yes No Type Amount per week How many hours of sleep do you get at night? Do you get enough sleep at night? Yes No Do you wake up feeling rested? Yes No Previous Operations PAST MEDICAL HISTORY Do you now or have you ever had: (check if yes ) Cancer Heart problems Asthma Goiter Leukemia Stroke Cataracts Diabetes Epilepsy Nervous breakdown Stomach ulcers Rheumatic fever Bad headaches Jaundice Colitis Kidney disease Pneumonia Psoriasis Anemia HIV/AIDS High Blood Pressure Emphysema Glaucoma Tuberculosis Other significant illness (please list) Natural or Alternative Therapies (chiropractic, magnets, massage, over-the-counter preparations, etc.) Type Year Reason 1. 2. 3. 4. 5. 6. 7. Any previous fractures? No Yes Describe: Any other serious injuries? No Yes Describe: FAMILY HISTORY: IF LIVING IF DECEASED Age Health Age at Death Cause Father Mother Number of siblings Number living Number deceased Number of children Number living Number deceased List ages of each Health of children: Do you know of any blood relative who has or had: (check and give relationship) Cancer Heart disease Rheumatic fever Tuberculosis Leukemia High blood pressure Epilepsy Diabetes Stroke Bleeding tendency Asthma Goiter Colitis Alcoholism Psoriasis
Drug allergies: No Yes To what? MEDICATIONS Type of reaction: PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.) Name of Drug Dose (include strength & number of pills per day) How long have you taken this medication Please check: Helped? A Lot Some Not At All 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. PAST MEDICATIONS Please review this list of arthritis medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided. Drug names/dosage Length of Please check: Helped? Reactions time A Lot Some Not At All Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Circle any you have taken in the past Ansaid (flurbiprofen) Arthrotec (diclofenac + misoprostil) Aspirin (including coated aspirin) Celebrex (celecoxib) Clinoril (sulindac) Daypro (oxaprozin) Disalcid (salsalate) Dolobid (diflunisal) Feldene (piroxicam) Indocin (indomethacin) Lodine (etodolac) Meclomen (meclofenamate) Motrin/Rufen (ibuprofen) Nalfon (fenoprofen) Naprosyn (naproxen) Oruvail (ketoprofen) Tolectin (tolmetin) Trilisate (choline magnesium trisalicylate) Vioxx (rofecoxib) Voltaren (diclofenac) Pain Relievers Acetaminophen (Tylenol) Codeine (Vicodin, Tylenol 3) Propoxyphene (Darvon/Darvocet) Disease Modifying Antirheumatic Drugs (DMARDS) Auranofin, gold pills (Ridaura) Gold shots (Myochrysine or Solganol) Hydroxychloroquine (Plaquenil) Penicillamine (Cuprimine or Depen) Methotrexate (Rheumatrex) Azathioprine (Imuran) Sulfasalazine (Azulfidine) Quinacrine (Atabrine) Cyclophosphamide (Cytoxan) Cyclosporine A (Sandimmune or Neoral) Etanercept (Enbrel) Infliximab (Remicade) Prosorba Column
PAST MEDICATIONS Continued Osteoporosis Medications Estrogen (Premarin, etc.) Alendronate (Fosamax) Etidronate (Didronel) Raloxifene (Evista) Fluoride Calcitonin injection or nasal (Miacalcin, Calcimar) Risedronate (Actonel) Gout Medications Probenecid (Benemid) Colchicine Allopurinol (Zyloprim/Lopurin) Others Tamoxifen (Nolvadex) Tiludronate (Skelid) Cortisone/Prednisone Hyalgan/Synvisc injections Herbal or Nutritional Supplements Please list supplements: Have you participated in any clinical trials for new medications? Yes No If yes, list:
ACTIVITIES OF DAILY LIVING Do you have stairs to climb? Yes No If yes, how many? How many people in household? Relationship and age of each Who does most of the housework? Who does most of the shopping? Who does most of the yard work? On the scale below, circle a number which best describes your situation; Most of the time, I function 1 2 3 4 5 VERY POORLY OK WELL VERY POORLY WELL Because of health problems, do you have difficulty: (Please check the appropriate response for each question.) Usually Sometimes No Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.)... Walking?... Climbing stairs?... Descending stairs?... Sitting down?... Getting up from chair?... Touching your feet while seated?... Reaching behind your back?... Reaching behind your head?... Dressing yourself?... Going to sleep?... Staying asleep due to pain?... Obtaining restful sleep?... Bathing?... Eating?... Working?... Getting along with family members?... In your sexual relationship?... Engaging in leisure time activities?... With morning stiffness?... Do you use a cane, crutches, as walker or a wheelchair? (circle one)... What is the hardest thing for you to do? Are you receiving disability?...yes No Are you applying for disability?...yes No Do you have a medically related lawsuit pending?...yes No