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
[email protected] (ordini)WWW.olisticnaturcenter.eu La strategia occulta delle lobbies del farmaco Marcello Pamio - 26 maggio 2007 Fonte: www.disinformazione.it Ogni tanto un farmaco usato da milioni di persone viene ritirato dal mercato perché provoca gravi danni all’organismo. Ogni tanto un farmaco viene ritirato perché provoca la morte stessa dei consumatori
FAI Sporting Code Section 3 – Gliding This document is valid from 1 October 2007 The FAI Sporting Code for gliders (SC3) sets out the rules and procedures to be used FEDERATION AERONAUTIQUE INTERNATIONALE Avenue Mon-Repos 24 – CH-1005 Lausanne - Switzerland All rights reserved. Copyright in this document is owned by the Fédération Aéronautique Internationale (FA