Duke Orthopaedics of Raleigh Patient Registration Form

Transcription

Duke Orthopaedics of Raleigh Patient Registration Form
Duke Orthopaedics of Raleigh
Patient Registration Form
FOR US TO PROCESS YOUR CHART, PLEASE COMPLETE FULLY AND PRINT CLEARLY
PATIENT INFORMATION:
NAME: _____________________________________________ TODAY’S DATE: ______________________________________
BIRTHDATE: ________________________AGE: _________
HOME PHONE #: ______________________________________
ADDRESS: _________________________________________ CELL PHONE #: _______________________________________
___________________________________________ ________ EMAIL:_______________________________________________
CITY
STATE
ZIP
EMPLOYMENT INFORMATION:
OCCUPATION: _______________________________________ EMPLOYER: ________________________________________
WORK PHONE #: ____________________________________
PAYOR INFORMATION:
INSURANCE PRIMARY: ______________________________ SUBSCRIBER: _________________________________________
SECONDARY: ______________________________________ SUBSCRIBER: _________________________________________
OTHER INSURANCE: _________________________________ SUBSCRIBER:_________________________________________
SOCIAL INFORMATION:
RACE (Circle One):
Multi-Racial
White
Unavailable
Black
Declined
ETHNICITY (Circle One):
Hispanic or Latino
LANGUAGE (Circle One):
English
MARITAL STATUS (Circle One):
Alaskan-Native
Asian
Hawaii-Pacific
All Other________________________________
Unavailable
Spanish
Single
American-Indian
Chinese
Married
Declined
Other____________________________
Other_________________________________________
Domestic Partner
Divorced
Separated
Widowed
CHILDREN: SONS? (Yes) (No)
DAUGHTERS? (Yes) (No)
How Many_______ How Many________
SPOUSE/PARENT
NAME (If a Minor):
___________________________________________________________
PRIMARY
CARE DOCTOR:
______________________________________________________________________________
I don’t have one
ADDRESS:
______________________________________________________________________
______________________________________________________________________
CITY
STATE
ZIP
PHONE #: __________________________________________________________________________
REFERRING HEALTHCARE PROFESSIONAL: _________________________________________________________________
(MD, PT, Chiropractor, etc.)
No one referred me
ADDRESS:__________________________________________________________________________
______________________________________________________________________
CITY
STATE
ZIP
PHONE #:___________________________________________________________________________
PREFERRED PHARMACY:__________________________________________________________________________________
I don’t have one
ADDRESS:
______________________________________________________________________
______________________________________________________________________
CITY
STATE
ZIP
PHONE #: ______________________________
FAX #: ______________________________
ORTHOPAEDIC INITIAL HEALTH HISTORY
F
NAME:_______________
AGE:______
HEIGHT:________
WEIGHT: ________
M
DID YOU BRING X-RAYS?
YES
NO
DID YOU BRING LABS?
YES
NO
WHO REQUESTED THAT YOU VISIT THIS OFFICE?
SELFREFERRAL
DOCTOR_________________________
ATTORNEY___________________________
WHAT IS THE MAIN REASON FOR THIS VISIT?
WHAT BODY PART IS INVOLVED? IF MULTIPLE, CHOOSE WORST
NECK
BACK
SHOULDER
L
R
ELBOW
L
R
HAND
L
ARM
L
WRIST
L
FINGER
L
R
R
R
R
PELVIS
L
R
KNEE
L
R
FOOT
L
R
HIP
L
R
ANKLE
L
R
TOE
L
R
HOW LONG HAS THIS PROBLEM BEEN PRESENT? ________
DAYS
WAS ONSET?
CONSTANT
GRADUAL OR
SUDDEN THE PAIN IS
ARE YOU RIGHT OR LEFT HANDED?
DID YOU HAVE AN INJURY?
RIGHT
YES
LEFT
NO
WEEKS
MONTHS
YEARS
COMES AND GOES (INTERMITTENT)
AMBIDEXTROUS
IF SO, WHAT WAS IT?
DATE OF INJURY:
AT WORK?
YES
NO
IN A MOTOR VEHICLE ACCIDENT?
YES
NO
IF YES, THEN ANSWER:
DRIVER
PASSENGER
RESTRAINED
UNRESTRAINED
HEAD-ON
REAR-ENDED
T-BONE PASSENGER SIDE
T-BONE DRIVER SIDE
AIRBAG DEPLOYED
SPEED_________
LITIGATION PENDING?
YES
NO
WHAT SEVERITY LEVEL WOULD YOU USE TO DESCRIBE YOUR PAIN? (ON A SCALE OF 0-10: 0=NO PAIN 10=WORST PAIN
0
1
2
3
4
5
6
7
8
9
10
HOW WOULD YOU DESCRIBE THE PAIN ASSOCIATED WITH THIS PROBLEM/INJURY? CHECK ALL THAT APPLY
ACHING
PULSATING
BURNING
SHARP
CONTINUOUS
THROBBING
DULL
TINGLING
EXCRUCIATING
OTHER_________
WHAT ACTIVITIES MAKE THE PROBLEM WORSE?
GRASPING
STANDING
TWISTING
GRIPPING
WALKING
TYPING/REPETITIVE
LIFTING
CLIMBING STAIRS
SQUATTING/KNEELING
OVERHEAD REACHING
DESCENDING STAIRS
OTHER_______
DO ANY OF THE FOLLOWING IMPROVE THE PROBLEM?
USING A BRACE/CANE
RESTING THE AREA
COLD APPLICATION
SLEEPING
HEAT APPLICATION
CORTISONE INJECTION
MEDICATION
OTHER __________
HAVE YOU HAD OTHER SYMPTOMS WITH THIS PROBLEM?
BRUISING
SWELLING
FEELING OF GIVING AWAY
TENDERNESS
LOCKING
WEAKNESS
NUMBNESS/TINGLING
OTHER ________
POPPING
WHAT HAVE YOU TRIED TO DO FOR THE PROBLEM? CHECK ALL THAT APPLY
REST
CORTISONE INJECTION
PHYSICAL THERAPY
SYNVISC/HYALGAN/SUPRAX
OTC MEDS (ADVIL, ALEVE, TYLENOL)
SURGERY
PRESCRIPTION NSAIDS
(LODINE, CELEBREX, NAIPROSYN)
OTHER ________
NARCOTICS
NOTICE AND RELEASE OF MEDICATION HISTORY:
I give permission for my physician to access my medication history from the National Surescripts Database.
Sign ______________________________________
Date _______________________
DRUG ALLERGIES
Are you allergic to any of the following? Please describe the reaction.
NO KNOWN ALLERGIES
Adhesive Tape____________________________________
Codeine_________________________________________
Erythromycin_____________________________________
Iodine/Betadine___________________________________
Morphine________________________________________
CURRENT MEDICATIONS
Penicillin______________________________
Radiographic dyes______________________
Sulfa_________________________________
Tetracycline___________________________
Latex_________________________________
Other______________________________
NONE
What medications are you currently taking? Please include both prescription and non-prescription medications.
Medications
Dose
Times per Day
_______________________ _______________________
_______________________
_______________________ _______________________
_______________________
_______________________ _______________________
_______________________
_______________________ _______________________
_______________________
_______________________ ________________________
________________________
_______________________ ________________________
________________________
PAST MEDICAL HISTORY:(Check all that apply)
□
□
□
□
□
□
□
□
□
□
NONE
AIDS/HIV
Alcohol Abuse
Alzheimer’s
Anemia
Asthma
Cancer_____________
COPD
Depression
Other
□
□
□
□
□
□
□
□
□
ALL NEGATIVE
Diabetes
Drug Abuse
DVT/PE
GERD/Reflux
Gout
Heart Disease
Hepatitis
High Blood Pressure
Kidney Disease
□
□
□
□
□
□
□
□
□
FALLS ASSESSMENT: Do you need assistance with ambulation (walking)?
Do you have a history of falling within the last 90 days?
Osteoporosis
Pacemaker
Rheumatoid Arthritis
Seizures
Sickle Cell Anemia
Sleep Apnea
Stroke
Ulcers
Use of Blood Thinners
(Yes)
(Yes)
FEMALE PATIENTS ONLY: Are you pregnant, or is there a chance you may be pregnant?
First day of last menstrual period ________________
PAST SURGICAL HISTORY:
(No)
(No)
(Yes)
(No)
ALL NEGATIVE
Have you ever had any of the following surgeries? Indicate the year of the surgery:
Appendectomy_________________________
Spine Surgery______________________________
Gall Bladder___________________________
Open Heart/By-pass_________________________
Hernia repair__________________________
Orthopaedic Surgery_________________________
Hysterectomy_________________________
Prostate Surgery____________________________
Arthroscopic Surgery___________________
Other (type & year)__________________________
Have you ever had a reaction to surgery or anesthesia?
Yes
No
Describe___________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
FAMILY MEDICAL HISTORY: (Check All that Apply)
Condition
□
□
□
□
□
ALL NEGATIVE
Relationship to Patient
Arthritis
Cancer
Diabetes
Heart Disease
High Blood Pressure
SOCIAL HISTORY
Alcohol Use
(Circle One): (Yes)
_______ Amount
_______ Frequency
_______ Year Quit
(No)
(Quit)
Drug Use:
(Circle One): (Yes) (No) (Quit)
Type(s)_________________________________ Years Used:_____________________________
Year Quit: _____________________________
Tobacco Use:
(Circle One): (Current Everyday)
(Current Someday)
Type:___________________________________
(Cigarettes, Cigars, Chewing, Pipe)
Year Quit:________________
(Former)
(Never)
Packs/day_______________________________
REVIEW OF SYSTEMS: (Check All that Apply OR Check All Negative Under Each Section)
□
Constitutional
All Negative
Weight Gain
□
□
Weight Change
□
□
Fever
□
□
HEENT
□All Negative
□
Headaches
□
□
□
Double Vision
Ringing in Ears
□
□
Respiratory
□
□
□
Chills
Night Sweats
□All Negative
Shortness of Breath
Cough
Wheezing
Difficulty Swallowing
Genitourinary
□
□
□
□All Negative
Frequency
Urgency
Blood in Urine
□
□
Cardiovascular
All Negative
Chest
Pain
□
□ Feel Heart Beating Hard
□
Gastrointestinal
All Negative
Nausea
□
Dark Stool or Blood
□
Stool
Heartburn
□
Fainting Spells
□All Negative
Musculoskeletal
Arthralgias
□
Gout
□
Osteoporosis
□
Skin
□All Negative
□
□
Rashes
Wound
□
Neurological
All Negative
Loss
of
coordination
□
□
Tremors
□
□
Vascular
□
□
□All Negative
DVT/Phlebitis
Open wounds that don’t heal
□
Seizures
Hematologic
All Negative
Easy
bruising
□
Easy bleeding
□
Everything I have answered above is true and correct to the best of my knowledge.
Patient Signature:______________________ Date__/__/__
Reviewed by MD:______________________ Date__/__/__