TRAVERSE CITY ORTHOPEDICSTraverse City Orthopedics and ...
PATIENT REGISTRATION FORMPatient’s name: ______________________________Nickname: _____________________Today’s Date: _____________Date of Birth: ________________ Age: ________ SS# __________________________ Gender: Male Female Mailing Address: _____________________________________________________________________ City/State/Zip: _______________________________________________________ Apt/Condo# ________Street Address (If different) _______________________________________ E-Mail: _________________________________Home #: (_____)__________________ Cell #: (_____)__________________ Work #: (_____)________________Employer_____________________________________________Occupation________________________________ Hand Dominance: FORMCHECKBOX RT FORMCHECKBOX LTPreferred Language: FORMCHECKBOX English FORMCHECKBOX Other: _____________________________Ethnicity: FORMCHECKBOX Not Hispanic or Latino FORMCHECKBOX Hispanic or LatinoRace: FORMCHECKBOX White FORMCHECKBOX Black or African American FORMCHECKBOX American Indian FORMCHECKBOX Asian FORMCHECKBOX Native Hawaiian FORMCHECKBOX Other RaceMarital Status: FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Widowed FORMCHECKBOX DivorcedCommunication Preference: FORMCHECKBOX Home Phone FORMCHECKBOX Cell Phone FORMCHECKBOX mail FORMCHECKBOX E-MailPharmacy you use: ___________________________________Pharmacy Location: _____________________________________Primary Care Physician: _____________________________________________________________________________________Spouse Information: Name ___________________________________________________ Date of Birth___________________________Address (if different) _________________________________________ City/State/Zip ______________________________________________Employer_________________________________________________ Work # __________________________________ Ext _______ Emergency Contact: Name: _____________________________ Relation: _____________________Phone: ________________________ *Contact methods agreement: By signing the authorization agreement on the next page, you agree, in order for us to service this account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which may result in charges to you. We may also contact you by sending text messages or emails, using any e-mail address you provided to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.Please initial: ________________________Insurance Information IS THIS A WORK INJURY? FORMCHECKBOX Yes FORMCHECKBOX NoPrimary: ____________________________________________IF SO, DID YOU FILE A CLAIM? FORMCHECKBOX Yes FORMCHECKBOX No IS THIS IS THIS AN AUTO INJURY? FORMCHECKBOX Yes FORMCHECKBOX NoSecondary: __________________________________________IF SO, DID YOU FILE A CLAIM? FORMCHECKBOX Yes FORMCHECKBOX NoAuthorization Agreements (For all patients to complete)I authorize my medical treatment, billing information and appointment times to be discussed without limitation with the person/people listed below.Name: __________________________________ Relation:__________________________ Ok to leave message? FORMCHECKBOX Yes FORMCHECKBOX NoName: __________________________________ Relation:__________________________ Ok to leave message? FORMCHECKBOX Yes FORMCHECKBOX NoName: __________________________________ Relation:__________________________ Ok to leave message? FORMCHECKBOX Yes FORMCHECKBOX NoName: __________________________________ Relation:__________________________ Ok to leave message? FORMCHECKBOX Yes FORMCHECKBOX NoACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESBy signing below, I acknowledge that I received a copy of this office’s Notice of Privacy Practices Form, or that one was offered to me.Patient / Guardian Signature: ______________________________________Date: ____/____/____(If patient is a minor, please have a parent sign)Authorization Agreement: I request that payment of authorized health insurance benefits be made on my behalf to Peter T. McAndrews III, D.O., P.C., Justin J. Hollander D.O., P.C., or Eric B. Lerche D.O., PC for any services furnished me. I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered. I authorize the doctor to release medical information, including HIV status (if requested) to my insurance company as needed to determine benefits. I also understand that I will be charged a $35.00 processing fee for any check I write that is returned due to non-sufficient funds. This signature further shows my consent to the contact methods agreement on page one of this form.______________________________________________________________/____/______Patient or responsible party signatureDateFOR ALL PEDIATRIC PATIENTS & YOUNG ADULTS (up to age 26)Parent’s InformationMother’s InformationName ___________________________________________ Date of Birth_____/_____/_____ SS# _______________________________Home Address_________________________________________________City/State/Zip__________________________________________Employer___________________________________Address_________________________________________________________________Home Ph#______________________________ Mobile phone# ________________________ Work # _________________________ext.____Father’s InformationName __________________________________________ Date of Birth_____/_____/_____ SS# ____________________________ Home Address_________________________________________________City/State/Zip__________________________________________Employer___________________________________Address________________________________________________________________Home Ph# ____________________________ Mobile phone# __________________________ Work # _________________________ext.____With whom does patient reside? (Check all that apply) FORMCHECKBOX Mother FORMCHECKBOX Father FORMCHECKBOX Joint Custody FORMCHECKBOX OtherWho is the guarantor? (Person responsible for bills) FORMCHECKBOX Mother FORMCHECKBOX Father FORMCHECKBOX Self (age 18-26)Who has legal custody of the child? FORMCHECKBOX Mother FORMCHECKBOX Father FORMCHECKBOX Joint Custody FORMCHECKBOX OtherOrthopedic History (page 1)Name :____________________________________ Date of Birth: _______________________ Today’s date: _____________________Chief ComplaintWhy are you seeing the doctor today? __________________________________________________________________________________Briefly describe onset/cause of symptoms: ______________________________________________________________________________Current problem is the result of a(n): check all that applyDate of Injury ___________________ FORMCHECKBOX Car accident FORMCHECKBOX Work accident FORMCHECKBOX Accident FORMCHECKBOX OtherWere you referred here by a physician? FORMCHECKBOX No FORMCHECKBOX YesPhysician’s name: ___________________________________________________Who is your family doctor? ____________________________________________ Phone # ________________________________________Review of SystemsAre you currently having or have you had problems with the following (please indicate “yes” even if controlled with medication): CircleDescribe all Yes responses, please be specificEyes, Ears, Nose, Throat FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Lungs, Breathing Disorders, Asthma FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________High Blood Pressure FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Heart Disease / CHF / MI FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Heart Murmur FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________CVA / Stroke FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Numbness / Tingling/ Paralysis FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Neurological/Psychological Disorder FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Depression/Anxiety FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________ Bleeding Disorders FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Gastrointestinal Disorders FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Cancer FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Thyroid Disease FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Diabetes FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Arthritis / Osteoporosis FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Polio / TB / AIDS / Hepatitis FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Skin Disorders FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Bowel / Bladder Disorders FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Kidney Disease / Dialysis FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Sleep Apnea FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________C-PAP FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________History of MRSA FORMCHECKBOX No FORMCHECKBOX Yes if yes, date of last nasal swab ______/______/______Other – please explain FORMCHECKBOX No FORMCHECKBOX Yes___________________________________________Patient Name: DOB: History (page 2)Past Medical History: FORMCHECKBOX NoneYear:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Past Surgical History – List All (not just orthopedic): FORMCHECKBOX NoneYear:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever had general anesthesia? FORMCHECKBOX No FORMCHECKBOX YesHave any problems with anesthesia? FORMCHECKBOX No FORMCHECKBOX YesDescribe: ___________________________________Social History FORMCHECKBOX Work in the home FORMCHECKBOX Employed (occupation ______________________) FORMCHECKBOX Student FORMCHECKBOX Daycare FORMCHECKBOX Retired FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Divorced FORMCHECKBOX Separated FORMCHECKBOX WidowedChildren? FORMCHECKBOX No FORMCHECKBOX Yes # _________Do you live alone? FORMCHECKBOX No FORMCHECKBOX YesExercise? FORMCHECKBOX Daily FORMCHECKBOX Weekly FORMCHECKBOX Monthly FORMCHECKBOX Rarely FORMCHECKBOX NeverWhat type of exercise? ___________________________________________________________________________History of substance abuse? FORMCHECKBOX No FORMCHECKBOX YesWhat? _____________________________________Smoking Status: FORMCHECKBOX Chews Tobacco FORMCHECKBOX Current Occasional Smoker FORMCHECKBOX Former Smoker FORMCHECKBOX Never smoked FORMCHECKBOX Current Every Day Smoker: please select a level… FORMCHECKBOX Heavy (20-30 cigs/day) FORMCHECKBOX Moderate (10-19 cigs/day) FORMCHECKBOX Light (1-9 cigs/day) FORMCHECKBOX Very Heavy (40+ cigs/day)Alcohol Use: FORMCHECKBOX Heavy FORMCHECKBOX Moderate FORMCHECKBOX Never FORMCHECKBOX Occasionally FORMCHECKBOX Past Abuse FORMCHECKBOX Daily FORMCHECKBOX RareTattoos? FORMCHECKBOX Location: _______________________Piercings? FORMCHECKBOX Location:____________________________Patient Signature: _________________________________________Date: _________________________Reviewed By: _____________________________________________Date: _________________________TELL ME ABOUT YOUR KNEE PROBLEMS:Please answer EVERY question on this form; it is required by your insurance companyName: _________________________________ Date of Birth:__________________ Today’s date: _____________________Affected Side: Right (R) or Left (L) or Both(Circle one)(Note: please answer for each knee separately if both sides are affected) How would you characterize the onset of7. What best describes your knee pain? your knee pain? R FORMCHECKBOX L FORMCHECKBOX Aching R FORMCHECKBOX L FORMCHECKBOX Sudden R FORMCHECKBOX L FORMCHECKBOX Sharp R FORMCHECKBOX L FORMCHECKBOX Gradual R FORMCHECKBOX L FORMCHECKBOX Throbbing R FORMCHECKBOX L FORMCHECKBOX Unknown R FORMCHECKBOX L FORMCHECKBOX Burning R FORMCHECKBOX L FORMCHECKBOX Tingling What has the pattern of your knee pain been? R FORMCHECKBOX L FORMCHECKBOX Intermittent R FORMCHECKBOX L FORMCHECKBOX Increasing R FORMCHECKBOX L FORMCHECKBOX Constant R FORMCHECKBOX L FORMCHECKBOX Decreasing R FORMCHECKBOX Other: _____________________________ R FORMCHECKBOX L FORMCHECKBOX Unchanging L FORMCHECKBOX Other: _____________________________ R FORMCHECKBOX L FORMCHECKBOX Episodic8. What aggravates your knee pain? R FORMCHECKBOX L FORMCHECKBOX SittingAbout how long has your knee hurt you? R FORMCHECKBOX L FORMCHECKBOX Twisting _______________________________ R FORMCHECKBOX L FORMCHECKBOX Getting out of a chair Any prior injuries to this extremity? R FORMCHECKBOX L FORMCHECKBOX Getting in and out of a carYes FORMCHECKBOX __________________ No FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX Riding in a car R FORMCHECKBOX L FORMCHECKBOX Prolonged walkingDoes your knee problem cause you to fall? R FORMCHECKBOX L FORMCHECKBOX Climbing stairs Yes FORMCHECKBOX No FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX Descending stairs R FORMCHECKBOX L FORMCHECKBOX Change in weather patternsWhere exactly is your knee pain located? R FORMCHECKBOX Other: ____________________________R FORMCHECKBOX L FORMCHECKBOX Entire knee L FORMCHECKBOX Other: ____________________________R FORMCHECKBOX L FORMCHECKBOX Front of kneeR FORMCHECKBOX L FORMCHECKBOX Back of knee9. What relieves your knee pain?R FORMCHECKBOX L FORMCHECKBOX Medial knee (inside, near other knee) R FORMCHECKBOX L FORMCHECKBOX NothingR FORMCHECKBOX L FORMCHECKBOX Lateral knee (away from other knee)R FORMCHECKBOX L FORMCHECKBOX HeatR FORMCHECKBOX L FORMCHECKBOX Under knee capR FORMCHECKBOX L FORMCHECKBOX IceR FORMCHECKBOX L FORMCHECKBOX Below knee cap R FORMCHECKBOX L FORMCHECKBOX Modification of activityR FORMCHECKBOX L FORMCHECKBOX Above knee cap R FORMCHECKBOX L FORMCHECKBOX Lying downR FORMCHECKBOX L FORMCHECKBOX CalfR FORMCHECKBOX L FORMCHECKBOX SittingR FORMCHECKBOX L FORMCHECKBOX Down the entire leg R FORMCHECKBOX L FORMCHECKBOX Walking assistive deviceR FORMCHECKBOX Other: _____________________________ R FORMCHECKBOX L FORMCHECKBOX Knee brace/sleeve (circle one)L FORMCHECKBOX Other: _____________________________R FORMCHECKBOX L FORMCHECKBOX Exercise R FORMCHECKBOX L FORMCHECKBOX StandingRate your knee pain 6 months ago.R FORMCHECKBOX L FORMCHECKBOX Walking R FORMCHECKBOX none=0 1 2 3 4 5 6 7 8 9 10=severe R FORMCHECKBOX L FORMCHECKBOX Topical Ointments L FORMCHECKBOX none=0 1 2 3 4 5 6 7 8 9 10=severe R FORMCHECKBOX L FORMCHECKBOX Lidoderm patchR FORMCHECKBOX L FORMCHECKBOX Medication Rate your average knee pain over the last week. R FORMCHECKBOX Other: _____________________________ R FORMCHECKBOX none=0 1 2 3 4 5 6 7 8 9 10=severe L FORMCHECKBOX Other: _____________________________ L FORMCHECKBOX none=0 1 2 3 4 5 6 7 8 9 10=severe Continued on next pageName: ______________________________________ Date of Birth:____________________ What are the associated features15. Have you had physical therapy for your of your knee pain? knee?R FORMCHECKBOX L FORMCHECKBOX Keeps me from sleeping at night Yes FORMCHECKBOX (if yes, when?)No FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX Frequently awakens me from sleep Start date: ________ End date: ___________R FORMCHECKBOX L FORMCHECKBOX Stiffness Location:______________________________R FORMCHECKBOX L FORMCHECKBOX Swelling R FORMCHECKBOX L FORMCHECKBOX Catching R FORMCHECKBOX L FORMCHECKBOX LockingR FORMCHECKBOX L FORMCHECKBOX Giving away16. Have you had any previous surgeries on R FORMCHECKBOX L FORMCHECKBOX Limping your knee?R FORMCHECKBOX L FORMCHECKBOX Grinding Yes FORMCHECKBOX No FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX Decreased range of motion (if yes, list the surgeries for each and whenR FORMCHECKBOX L FORMCHECKBOX Swelling in the leg they were done)R FORMCHECKBOX L FORMCHECKBOX Difficulty shopping ___________________________________R FORMCHECKBOX L FORMCHECKBOX Difficulty doing housework ___________________________________R FORMCHECKBOX L FORMCHECKBOX Difficulty with sports ____________________________________R FORMCHECKBOX L FORMCHECKBOX Difficulty walking a distance ____________________________________11. How far can you walk without pain? 17. Which assistive device do you use? FORMCHECKBOX < 100 feet FORMCHECKBOX None FORMCHECKBOX 100-200 feet FORMCHECKBOX Cane FORMCHECKBOX > 200 feet FORMCHECKBOX Crutch FORMCHECKBOX Walker12. What initially brought on your knee pain? FORMCHECKBOX Wheelchair R FORMCHECKBOX L FORMCHECKBOX Not sure FORMCHECKBOX Shopping basket R FORMCHECKBOX L FORMCHECKBOX Trauma FORMCHECKBOX Shopping basket R FORMCHECKBOX Other: ____________________________ L FORMCHECKBOX Other: ____________________________ 13. What previous diagnostic tests have you had18. What medications have you taken? on your knees? Helped Did not help R FORMCHECKBOX L FORMCHECKBOX None R FORMCHECKBOX L FORMCHECKBOX Plain radiographs ______None FORMCHECKBOX FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX MRI ______Tylenol FORMCHECKBOX FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX CT Scan ______Aspirin FORMCHECKBOX FORMCHECKBOX R FORMCHECKBOX L FORMCHECKBOX Bone Scan ______Motrin FORMCHECKBOX FORMCHECKBOX ______Aleve FORMCHECKBOX FORMCHECKBOX 14. Note if any of the following have evaluated or ______ NSAID FORMCHECKBOX FORMCHECKBOX treated your back or lower extremities. ______Ultram FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Orthopedic surgeon ______Narcotic: _____ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Neurosurgeon ______Glucosamine FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Neurologist ______Steroid injection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Rheumatologist ______Hyaluronic acid FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Chiropractor injection FORMCHECKBOX Pain management physician ______Other: ________ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other: _______________________________ 19. How would you characterize your knee problem?Patient Signature:__________________________________ Date: Time: R FORMCHECKBOX L FORMCHECKBOX An inconvenience R FORMCHECKBOX L FORMCHECKBOX More than an inconvenience Physician Signature: ________________________________ R FORMCHECKBOX L FORMCHECKBOX DisablingDate: Time:ALLERGY / MEDICATION RECORDPatient Name: _____________________________________ Date of Birth: ___________________ Date: _______________ ALLERGIES Please List All ALLERGIES and Reactions: FORMCHECKBOX No Known Drug Allergies Medication ReactionAre you allergic to Egg, Egg Products, or Poultry? FORMCHECKBOX No FORMCHECKBOX Yes Reaction: ______________________Are you allergic to Latex? FORMCHECKBOX No FORMCHECKBOX Yes Reaction: ______________________Are you allergic to any Metals? FORMCHECKBOX No FORMCHECKBOX Yes: ________________________________Have you ever had a reaction to costume jewelry? FORMCHECKBOX No FORMCHECKBOX Yes Reaction: ______________________Please list any other allergies: _______________________________________________________________________________PHARMACY YOU USE: ___________________________PHARMACY ADDRESS: __________________________________MEDICATIONSPlease list all prescription medications, supplements, and over-the-counter medications you take on a daily basis: FORMCHECKBOX No Medications Medication Dosage FrequencyPatient Signature: _________________________________________________________ Date: __________________________ ................
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