Update 1/6/2021 Sarasota Arthritis Center

Sarasota Arthritis Center

Update 1/6/2021

Welcome to Sarasota Arthritis Center! We are delighted you have chosen our practice for your medical care. This packet MUST be completed and returned to book your appointment with one of our rheumatologists.

OFFICE LOCATIONS

Sarasota Arthritis Center 1945 Versailles St Sarasota, FL 34239 941-365-0770

Bradenton Arthritis Center 5308 4th Ave Circle East Bradenton, FL 34208 941-567-4021

Venice Arthritis Center 411 Commercial Ct, Ste D Venice, FL 34292 941-484-4409

Englewood Arthritis Center 684 S Indiana Ave Englewood, FL 34223 941-475-3839

*IT IS IMPORTANT TO ARRIVE AT LEAST 30 MINUTES PRIOR TO YOUR APPOINTMENT TIME. IF YOU ARE LATE, YOUR APPOINTMENT MAY BE CANCELLED. *

Please reference the following information to help prepare for your visit: Have all applicable records (office notes, MRI results, lab work results, x-ray results, etc.) faxed to our New Patient Coordinators at 941-955-8977. Please note that it is the patient's responsibility to obtain these records. Bring a picture ID to your appointment. Bring your current insurance card(s) to your appointment and to each follow up appointment thereafter. Expect to be in our office 60-90 minutes. Please keep this page. Return the rest of this packet via one of the following: ? Mail to : 1945 Versailles St, Sarasota, FL 34239 ? Fax to: 941-955-8977 ? Drop off at one of our locations ? Encrypted email to: ? brenda@ ? janice@ ? allison@

We take great pride in our ability to provide a personalized approach to each patient. We appreciate the opportunity to participate in your rheumatologic care. We look forward to seeing you!

Sarasota Arthritis Center

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Sarasota Arthritis Center

Update 1/6/2021

PATIENT REGISTRATION

Patient Information (please print clearly)

Patient Last Name

First Name

Middle Initial Date of Birth (Month/Day/Year) Sex

Mailing Address

City

State

Zip Code

Alternate Address

City

State

Zip Code

Home Number

Cell Number

Alternate Number

Activate Patient Portal Email Address Yes No

Primary Language Do You Need an Interpreter? Ethnicity Yes No

Hearing Impaired? Yes No

Vision Impaired? Yes No

Retired

Employer Name

Yes No

Employer Address, City, State

Employer Telephone

Emergency Contact Information

Last Name

First Name

Relationship to Patient Contact Number

Medical Insurance Policy Holder Primary Insurance Company

Policy Holder Last Name

Check Here if Uninsured Policy Holder First Name

Relationship to Patient

Subscriber ID

Group Number

Date of Birth (Month/Day/Year)

Secondary Insurance Company

Policy Holder Last Name

Policy Holder First Name

Relationship to Patient

Subscriber ID

Group Number

Date of Birth (Month/Day/Year)

Responsible Party If Other Than Patient

Last Name

First Name

Relationship to Patient Contact Number

Street Address

City

State

Zip Code

Please indicate if you have any of the following OPEN CLAIMS: Workers Compensation: Yes No Auto Accident: Yes No

If you have answered yes to any of these, please explain:

Slip and Fall/other Liability: Yes No

Assignment of Benefits / Consent for Treatment

I do hereby assign all medical benefits to which I am entitled, including all government and private insurance plans to this office. This assignment will remain in effect until revoked by me in writing. I acknowledge receipt of the Financial Policy and I understand that I am responsible for all charges not paid by insurance. I authorize this practice to release all information necessary to secure payment. I hereby voluntarily consent to treatment at this office and authorize such treatments, examinations, medications, and diagnostic procedures (including but not limited to lab and radiographic studies) as ordered by attending providers.

Signature of Patient/Guardian/Legal Representative

Date (Month/Day/Year)

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Sarasota Arthritis Center

MEDICAL HISTORY

Patient Information (please print clearly)

Last Name

First Name

Middle Initial

Update 1/6/2021

Date of Birth (Month/Day/Year)

Reason for Visit

Primary Care Doctor

Name Address

Phone Number Group Practice Name

Preferred Pharmacy Information

Pharmacy Name Address

Phone Number Specialty Pharmacy

List medications that you have tried in the past for your autoimmune condition(s)

1.

Mg 3.

Mg

2.

Mg 4.

Mg

List your current medications -or- provide current med list (INCLUDING any over the counter, supplements,

injections, etc)

Frequency Dose

Frequency Dose

1.

Mg 7.

Mg

2.

Mg 8.

Mg

3.

Mg 9.

Mg

4.

Mg 10.

Mg

5.

Mg 11.

Mg

6.

Mg 12.

Mg

Past Surgical History (List past major surgeries, year, left/right side if applicable)

1.

4.

7.

2.

5.

8.

3.

6.

9.

Allergies (List all allergies and reactions ? drugs, latex, others, etc)

1.

3.

5.

2.

4.

6.

*USE BACK OF PAGE IF NECESSARY*

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Sarasota Arthritis Center

Patient Information (please print clearly)

Last Name

First Name

Update 1/6/2021

Middle Initial Date of Birth (Month/Day/Year)

Past Medical History (Check formal diagnoses for which you may or may not take medications & approximate year of onset)

Year

Year

Year

High Cholesterol

Pleural Effusion

Depression

Hypertension/ High BP

Pericardial Effusion

Anxiety

Type I Diabetes

Asthma

Insomnia

Type II Diabetes

COPD or Emphysema

Obstructive Sleep Apnea

Thyroid Disease [type] Chronic Kidney Disease

Cancer [type] GERD/ Acid Reflux

Alcoholism or Drug Addiction

[circle]

HIV or STD [circle]

Renal or Kidney Stones

Stomach Ulcer

Lyme Disease

Blood clots/DVT/PE

[circle]

Coronary Artery Disease

Fatty Liver Hepatitis B

Major Trauma XRT/Radiation Therapy

Congestive Heart Failure

Arrythmia [Irregular

heartbeat]

Stroke

Hepatitis C Celiac Disease

Irritable Bowel Syndrome

Tuberculosis

Other conditions not listed, write below

Bleeding Disorder

Seizure Disorder

Pulmonary Hypertension

Multiple Sclerosis

Interstitial Lung Disease

Migraine

Past Medical History ? Rheumatology Specific (Check formal diagnoses and give year of onset

Year

Osteoarthritis [location]

Fibromyalgia

Year

Year

Polymyalgia Rheumatic (PMR)

Degenerative discs in

cervical spine

Osteopenia

Osteoporosis

Fracture spine or hip

[circle]

Fracture other site

Specify:

Autoimmune liver or

autoimmune thyroid disease [circle]

Gout

Rheumatoid Arthritis

Systemic Lupus

Erythematosus (SLE)

Discoid Lupus

Systemic vasculitis [type]

Iritis or Uveitis or Scleritis

[circle]

Psoriasis

Psoriatic Arthritis

Ulcerative Colitis or Crohn's

Disease [circle]

Ankylosing Spondylitis

Other (specify)

Other (specify)

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Sarasota Arthritis Center

Patient Information (please print clearly)

Last Name

First Name

Update 1/6/2021

Middle Initial Date of Birth (Month/Day/Year)

Family History (Check if family member has CONFIRMED diagnosis and give relationship)

Osteoarthritis

Who:

Psoriasis

Who:

Paternal / Maternal [circle] Paternal / Maternal [circle]

Osteoporosis

Crohn's Disease

Who:

Who:

Paternal / Maternal [circle]

Gout

Who:

Paternal / Maternal [circle]

Ulcerative Colitis

Who:

Paternal / Maternal [circle]

Rheumatoid Arthritis

Who:

Paternal / Maternal [circle]

Ankylosing Spondylitis

Who:

Paternal / Maternal [circle]

Systemic Lupus

Who:

Paternal / Maternal [circle]

Iritis or Scleritis

Who:

Paternal / Maternal [circle] Paternal / Maternal [circle]

Polymyalgia Rheumatica

Who:

Blood clots

Who:

Paternal / Maternal [circle]

Systemic Vasculitis

Who:

Paternal / Maternal [circle]

Hypertension

Who:

Paternal / Maternal [circle]

Parent w/ hip/spine fracture

Who:

Paternal / Maternal [circle]

Diabetes

Who:

Paternal / Maternal [circle]

Cancer

Who:

Paternal / Maternal [circle]

Heart Disease

Who:

Paternal / Maternal [circle]

Tuberculosis

Who:

Paternal / Maternal [circle]

Stroke

Who:

Paternal / Maternal [circle]

Paternal / Maternal [circle]

Social History

Cigarette Smoking/Tobacco Use If yes, quantity per day:

Yes No N/A

If yes, how long?

Did you quit?

Yes No

What age did you quit?

Use E-Cigarettes

Yes No

N/A

If yes, quantity per day:

If yes, how long?

Did you quit?

Yes No

What age did you quit?

Drink alcohol?

Yes No N/A

If yes, quantity per day:

If yes, how long?

Did you quit?

Yes No

What age did you quit?

Health Assessment (MDHAQ)

Considering all the ways in which illness/health conditions may affect you at this time, please indicate how you are doing:

Very Well

Very Poorly

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10

OVER THE PAST WEEK, how much pain have you had because of your condition? No Pain

Pain - as bad as it could be

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8 8.5 9 9.5 10

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