Orthopedic Clinic Visit
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Demographics
ProviderPlease SelectRyan Arnold, MDEric Bonness, MDBryan Bredthauer, MDDavid Brown, MDNicholas Bruggeman, MDCharles Burt, MDJonathon Buzzell, MDJames Canedy, MDJeffrey Ebel, DOThomas Ferlic, MDTodd Gaddie, MDMark Goebel, MDSteven Goebel, MDGeorge Greene, MDKevin Grosshans, MDSteven Hagan, MDMatthew Hahn, MDCraig Hansen, MDKirk Hutton, MDSayfe Jassim, MDSteven Kumagai, MDAlex Lesiak, MDKelsey Mitchell, PA-CMichael O’Neil, MDNoah Porter, MDScott Reynolds, MDEric Samuelson, MDWilliam Singer, MDNada Skaf, MDAndrew Thompson, MDMichael Thompson, MDJoshua Urban, MDKathryn Wildy, MD
Appointment
Patient Name *
Gender * Male Female
Marital Status * Please SelectDivorcedLife PartnerMarriedSeparatedSingleWidowed
Social Security Number
Birth Date *
Ethnicity * Please SelectNon-Hispanic or LatinoHispanic or LatinoDeclined to Specify
Race * Please SelectCaucasian (White)Black/African-AmericanAsianNative AmericanAsian/Pacific IslanderPacific IslanderSubcontinent Asian AmericanAmerican Indian or Alaskan NativeNative HawaiianOther RaceMore than One RaceNot Reported/Refused
Preferred Language
Primary Care Physician(enter “none” if none)
Patient Address *
Patient Phone *
E-Mail Address
Employment Status * Please SelectFull TimePart TimeRetiredDisabledStudentOther
If Retired/Disabled, Date of Retirement/Disability
Employer/School *
Reason for Visit *
Advanced Directive? * Yes No
Encounter Information
Date & Time of Accident/Injury *
Due to a Motor Vehicle Accident? * Yes No
Due to a Workmans’ Comp Injury? * Yes No
Guarantor/Patient Information (if patient is a MINOR – info for person receiving Billing Statement)
Name
Birthdate
Relationship to Patient
Guarantor Address
Guarantor Phone
Guarantor Employer
Primary Insurance
Subscriber’s Name
Relationship
Birth Date
Subscriber’s Home Address
Employer Information Full Part-time
Insurance Information
Secondary Insurance
Emergency Contact
Name *
Primary Phone *
Relationship to Patient *
Health History
Patient Information *
Referred by *
Primary Physician *
Current Injury/Complaint
Chief Complaint * Right Left Bilateral
Body part *
History of Present Illness: Answer these questions regarding your current problem(s) only.
What symptoms are you experiencing? How did it happen? *
How long have you had this problem? *
What is the date of injury? *
Is this a sports-related injury? * Yes No
If yes, please name school/club
Is this the result of an auto accident? * Yes No
Date of injury
Is this a Workers’ Compensation case? * Yes No
Do you have an attorney assisting you? * Yes No
Is there any other legal action pending? * Yes No
Check any previous treatment(s) you’ve had for this problem if applicable: Anti-Inflammatories/NSAIDS Bracing Chiropractor Cold Therapy Emergency Room Injection Medication Physical Therapy Relaxation/Rest Repositioning Surgery None Other Treatments
Have you had any of the following diagnostic studies for your current problem?
CT * Yes No
EMG/NCV * Yes No
Epidural/steroid injection * Yes No
MRI * Yes No
Myelogram * Yes No
X-Rays * Yes No
Other * Yes No
On a scale of 1-10, how severe is your pain? (0 = no pain present - 10 = worst pain of your life) *
Pain Description: Aching Burning Dull Numbness Pressure Sharp Shooting Throbbing Tingling Unable to describe Other
Do any of the following activities make it worse? (Check all that apply) Activities of Daily Living Exercise Lifting Lying Down Rising from a Chair Sitting Standing Walking Other
Medications
Allergies to medications, X-ray dye, metals and/or soaps? No Known Allergies Yes, please list and indicate reaction
Please list all current medications and dosages, or bring current list to your scheduled appointment * I am currently not taking any medications prescribed or over-the-counter I am currently taking medications prescribed or over-the-counter
Pharmacy *
Social History
Do you use any of the following? (check all that apply)
Smoking Tobacco * Never Current Former
Smokeless Tobacco * Never Current Former
Electronic Cigarettes/Vaping * Never Current Former
Alcohol Current 1-2 times per Week Month Year Past Never
Non-prescription, mind-enhancing drugs or performance enhancing drugs (please list)
Do you exercise regularly * Yes No
How many times per week Daily 1-2 3-4 5-6
Employer
Retired Disabled Unemployed
What kind of work do you do
Are you a student? Yes No
If yes, please list your grade and school name
Family History - check where applicable
Anesthesia Problems Father Mother Sister Brother
Cancer Father Mother Sister Brother
Bleeding/Clotting (DVT) Father Mother Sister Brother
Diabetes Father Mother Sister Brother
Gout Father Mother Sister Brother
Heart Disease Father Mother Sister Brother
High Blood Pressure Father Mother Sister Brother
Stroke Father Mother Sister Brother
Past Medical History - check all that apply
Heart Disease Lung Disease Asthma Diabetes Gastric Ulcer Anxiety Depression Osteoarthritis Stroke Dementia High Blood Pressure Cancer Kidney Disease Blood Disorder Thyroid Disorder Osteoporosis Liver Disease Fibromyalgia Gout Skin Infection MRSA Cellulitis Sleep Apnea/C-PAP Blood Clots/DVT Pulmonary Embolism Multiple Sclerosis Claustrophobia Hepatitis A B C HIV Reaction to Anesthesia Other Other
Procedure History - Please list all past procedures
None Orthopaedic (procedure and date) Stent Placement (date) Heart Bypass (date) Other Pacemaker Hysterectomy Appendectomy Gallbladder Sinus C-Section Tubal Ligation Tonsils Tubes (ear) Vasectomy
Review of Systems Mark current systems
Constitutional Normal Chills Fever Night Sweats Obesity Weight Change
Cardiovascular Normal Chest Pain Difficulty Breathing
Hema/Lymph Normal Bleeds Easy Bruises Easy
Musculoskeletal Normal Other Joint Pain
Psychiatric Normal Depression Anxiety
HEENT Normal Headache Hearing Loss Tooth Pain Visual Problems
Gastrointestinal Normal Heartburn/Acid Reflux Nausea Vomiting
Endocrine Normal Excessive Sweating Excessive Thirst
Integumentary Normal Rashes Skin Lesions
Respiratory Normal Shortness of Breath
Genitourinary Normal Urinary Frequency Urinary Incontinence
Immunologic Normal Seasonal Allergies Swollen Neck Glands
Neurologic Normal Motor Disturbances Numbness Tingling Vertigo/Dizziness
Health Promotion
Have you been discharged from a nursing facility, hospital or skilled rehabilitation facility in the last 30 days? * Yes No
Are you 64 years of age or older?
Advanced Care Planning Do you have an Advance Directive? Yes No If yes, please consider providing a copy for your medical record at your next visit
Are you interested in receiving additional information on Advanced Directives? Yes No
Fall Prevention Are you non-ambulatory (wheelchair bound or bedridden)? Yes No
Have you fallen in the past year? Yes No
If yes, how many times
If yes, were you injured? Yes No
Do you feel unsteady standing or walking? Yes No
Do you worry about falling? Yes No
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.