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Microsoft word - copy of pt reg 2.doc

Patient Registration
NEO Foot & Ankle Surgical Associates, Inc 1 PATIENT INFORMATION
TODAY’S DATE______________________________________________ PATIENT’S LAST NAME_______________________________FIRST_______________________________MIDDLE INITIAL__________________ MAILING ADDRESS_________________________________________________________________APT NO________________________________ CITY___________________________________________________STATE______________________ZIP CODE______________________________ HOME PHONE: ______________________________________________CELL PHONE: ________________________________________________
PATIENT E-MAIL ADDRESS_________________________________________________________________________________________________ SEX: MALE: ______ FEMALE: _______ AGE: ________ DATE OF BIRTH________________SS#_________________________________
HEIGHT________ WEIGHT________SHOE SIZE____________ HOSPITAL OF CHOICE: _____________________________________________ Single______ Married______ Widowed______ Separated______ Divorced__________ OCCUPATION_________________________________________EMPLOYER__________________________________________________________ EMPLOYER ADDRESS__________________________________________EMPLOYER PHONE: ________________________________________
SPOUSE’S NAME___________________________________________________________________________________________________________ NAME OF PARENT OR GUARDIAN (IF PATIENT IS A MINOR)___________________________________________________________________ PARENT/GUARDIAN SS#_________________________________PARENT/GUARDIAN DATE OF BIRTH________________________________ 2 REFERRAL INFORMATION – HOW DID YOU FIND OUT ABOUT US?
_______FAMILY MEMBER/FRIEND and NAME________________________________
_______DR.________________________________ _______PHONE BOOK/YELLOW PAGE _______INTERNET/WEB SITE _______INSURANCE BOOK _______HOSPITAL 3 INSURANCE **PLEASE PRESENT YOUR INSURANCE CARD & DRIVER’S LICENSE TO THE RECEPTIONIST.
LAST NAME OF INSURED__________________________________FIRST NAME__________________MIDDLE INITIAL___________________ RELATIONSHIP TO PATIENT________________________________________________________________________________________________ INSURED’S SS#_____________________________________________________INSURED’S DATE OF BIRTH____________________________
Will not be seen if this information is missing.
LAST NAME OF INSURED__________________________________FIRST NAME__________________MIDDLE INITIAL___________________ RELATIONSHIP TO PATIENT________________________________________________________________________________________________ INSURED’S SS#_____________________________________________________INSURED’S DATE OF BIRTH____________________________
Will not be seen if this information is missing.
LAST NAME OF INSURED__________________________________FIRST NAME__________________MIDDLE INITIAL___________________ RELATIONSHIP TO PATIENT________________________________________________________________________________________________ INSURED’S SS#_____________________________________________________INSURED’S DATE OF BIRTH___________________________
Will not be seen if this information is missing.
NEO Foot & Ankle Surgical Associates, Inc
4 CHIEF COMPLAINT: What is the chief complaint for which you came to be treated? (Include foot, ankle, knee, thigh, and
hip complaints.) ___________________________________________________________________________________________________________ 5 PATIENTS HISTORY OF PRESENT ILLNESS (WHY YOU ARE HERE):
(OKAY TO CIRCLE)
Other: _______________________________________ Alleviating Factors: (What makes the pain better?)
Aggravating Factors: (What makes the pain worse?)
 Pain Medicine: ______________________  Pain Medicine: _______________________.
 Acupuncture  Anti-inflammatory Medications  Biofeedback  R.I.C.E. Therapy (Rest, Ice, Compression, Elevation)  Any other treatment options: __________________________________ Is this a work-related injury?  Yes  No What is the date of the injury? ___________________________________________ Where did the injury occur? _______________________________________________________________________________________ If the injury occurred at work, has your employer been notified?  Yes  No Have you filed a “Report of First Injury” Employer_________________________________________________Occupation____________________________________________ Employer Phone #________________________________________Contact Person___________________________________________ NEO Foot & Ankle Surgical Associates, Inc
6 MEDICAL HISTORY – Please indicate problems you now have or have had in the past.
Are you now, or have you been, under any other doctor’s care for any reason over the past two years? Doctor Name: ______________________ Number: __________________ Reason: _________________________ Doctor Name: ______________________ Number: __________________ Reason: _________________________ Doctor Name: ______________________ Number: __________________ Reason: _________________________ Doctor Name: ______________________ Number: __________________ Reason: _________________________ Doctor Name: ______________________ Number: __________________ Reason: _________________________ NEO Foot & Ankle Surgical Associates, Inc
7 MEDICATIONS – Please list all medications from all physicians.
ARE YOU CURRENTLY ACCEPTING PAIN/NARCOTIC MEDICATIONS FROM ANY OTHER SOURCE:
 NO  YES NAME OF PHYSICIAN/SOURCE: ___________________________. NUMBER: ___________________________
If you are accepting narcotics from another source and do not disclose it, you will be released from this practice.
Antidepressants: Elavil Amityptilline Prozac Effexor Zoloft Deseryl
Serozone Desipiramine Remeron Pamelor Paxil Other: ________________________________________________________
Blood Thinners: Aspirin Coumadin (Warfarin) Fragmin (Dalteparin) Garlic Pills Heparin Lovenox (Enoxaparin)
Plavix Any other blood thinners: __________________________________________________________________________________
Diabetic Medication: Glyburide Glipzide Glimepiride Metformin Precose Avandia Actos Starlix Prandin
Januvia Byetta Novolin N Levemir Lantus Novolin 70/30 Novolin R Novolog Other: __________________________
Narcotics: Darvocet Vicodin Percocet Demerol Dilaudid Morphine
MS Contin Oxycontin Tylox Tylenol 3 Methadone Other: ______________________________________________________
Neuropathic Pain Medications: Neurontin Klonopin Tegretol Dilantin
Ultram Prozocin Mexitil Prazocin Other: _____________________________________________________________________
NSAIDS: Aspirin Ibuprofen Advil Motrin Naprosyn Mobic Aleve Celebrex Other: _________________________
Relaxants: Ativan Baclofen Flexeril Librium Paxil Valium Xanax Other: __________________________________
Sleep Medicines: Ambien Restoril Benedryl Halcion Other:____________________________________________________
Medication: __________________ Dose: ______________ Medication: ______________________Dose: ______________________ Medication: __________________ Dose: ______________ Medication: ______________________Dose: ______________________ Medication: __________________ Dose: ______________ Medication: ______________________Dose: ______________________ Do you take oral contraceptives?  Yes  No Preferred Pharmacy Name______________________________________Pharmacy Phone # ___________________________________ 8 ALLERGIES – Mark any that apply:
REACTION: ____________________________________________________________________________________________________ REACTION: ____________________________________________________________________________________________________ REACTION: ____________________________________________________________________________________________________ 9 PAST SURGICAL HISTORY
Surgery___________________________________________________________Date_________________________________________ Surgery___________________________________________________________Date_________________________________________ Surgery___________________________________________________________Date_________________________________________ Surgery___________________________________________________________Date_________________________________________ Surgery___________________________________________________________Date_________________________________________ Hospitalizations other than for surgeries listed_________________________________________________________________________ Family Physician______________________________________________Date of last visit_____________________________________ Address_____________________________________________________Phone #____________________________________________ 10 SOCIAL HISTORY
Alcohol Use: Drinks per day___________ Other Drug Use: ______________Tobacco Use: YES NO Years Smoked____________ Employment Status: __________________________________________________ Athletic activities in which you participate ____________________________________________________________________________ 11 FAMILY HISTORY
SIGNATURE ON FILE & PERMISSION TO TREAT
I request that payments of authorized benefits on my behalf for any services furnished me by Northeastern Ohio Foot &
Ankle Surgical Associates, Inc. I authorize any holder of information about me to release any information needed to
determine these benefits or the benefits payable to related services to the insurance agent. I recognize my financial
obligation of any co-insurance, co-pays, or deductibles and non-covered services that may be required. I give permission to
Northeastern Ohio Foot & Ankle Surgical Associates, Inc. to examine, photograph, administer, and perform such minor
operative procedures as may be deemed necessary in the diagnosis and/or treatment of my foot and/or ankle problems.
Signed____________________________________________________________Date________________________________________ PRIVACY STATEMENT
Northeastern Ohio Foot & Ankle Surgical Associates, Inc. will use and disclose your health information for the following
purposes: to treat you, to assist other health care providers in treating you, to allow insurance companies to process
insurance claims for services rendered to you, to obtain payment for services rendered to you and for certain limited
operation activities, such as quality assessment, licensing, accreditation and training of students. Except as stated in more
detail in the Notice of Privacy Practices, we will not use or disclose your health information without your written
authorization. If you have any questions, concerns, or complaints regarding our privacy practices, please refer to the
actual Notice of Privacy Practices provided to you for the person(s) whom you may contact.
Additional Disclosure Authority: In addition to the allowable disclosures described in the State of Privacy Practices, I
hereby specifically authorize disclosure of my protected health care information to the persons indicated below.
OTHER (PLEASE SPECIFY)________________________________  YES  NO Acknowledgement of Receipt of Notice of Privacy Practices: (Signature represents that I have been offered a copy of the policy) ____________________________________________ ___________________________________________Patient or Authorized Representative’s Initials Date

Source: http://neofasa.homestead.com/PTREG2.pdf