Midwest Orthopedic Specialists » Patient Information

Patient Information

Name *

First

Middle

Last

Name you go by

Address

City

State

Zip

Preferred Phone

Alternate Phone

Contact Preference

Call
Text
Email

Sex

Age

Birthdate

Marital Status

Single
Married
Widowed
Separated
Divorced

Patient Social Security #

Who lives in your home with you?

Race

American Indian
Asian
Black
Native Hawaiian
Type-Unknown
White

Ethnicity

Hispanic Origin
Non-Hispanic
Type-Unknown

Language

Employer

Work Phone #

Employer Address

Job Duties

Parent/Guardian Name:

DOB

Employer

Spouse's Name

DOB

Spouse's SSN #

Spouse's Employer

Employer Address

Spouse's Work Phone #

Spouse's Cell Phone #

Emergency Contact

Emergency Contact Name *

First

Last

Relationship

Home Phone

Work Phone

Medicare Authorization

I request that payment of authorized Medicare benefits be made on my behalf to Midwest Orthopedic Specialists for any services furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered services. Coinsurance and deductible are determined by the Medicare carrier.

Electronic Signature *

First

Last

Date

Assignment and Release

I, the undersigned, hereby AUTHORIZE Midwest Orthopedic Specialists to furnish information to insurance carriers and/or healthcare facilities concerning my illness or treatments. I also assign any benefits to Midwest Orthopedic Specialists for services rendered by the physician(s). I understand that I am responsible for any amount not covered by insurance. I understand that payment in full is due upon the rendering of services, If the account becomes delinquent and is referred to a collection agency and/or attorney, the undersigned agrees to pay all collection agency fees, attorney’s fees, and expenses. If a suit is filed to enforce collection, it may be filed in the county where this Agreement is being signed and entered into.

Electronic Signature *

First

Last

Date

Accident Details

Date, Time, & Place of Accident

Relation of Injury

Work
Auto
Other

Details of Accident

Please note if any Liability Insurance involved (Auto, Homeowners, Liability)

Name, Address & Phone Number of Attorney (if one is representing you in this accident)

Do we have authorization to release information to the above listed attorney?

Electronic Signature *

First

Last

Date

History of Chief Complaint

What body part are you seeing the doctor for today?

Explain your symptoms leading to today's visit:

How long have you had this problem?

Recurrent
New
Chronic

Describe your discomfort:

Sharp
Dull
Numb
Aching

Other

Pain Scale (0=no pain, 10=worst pain)

Does the joint

Give way
Catch

Tried to relieve symptoms with:

Medication
Therapy
Heat/Ice
Braces
Injection
Home Exercise

Other

How long have you tried these for relief?

What makes your pain better?

What make your pain worse?

Have you had any x-rays, MRI, CT for this problem?

Is this problem a result of an injury/accident?

Providers

Primary Care:

Referred By:

Specialty Providers:

Pharmacy

Preferred Pharmacy

Location

Surgical History

Please check if you have had any of these surgeries in the past:

No Surgical History
Ankle surgery
Appendectomy
Back surgery
Breast surgery
CABG
Carpal Tunnel Release
Defibrillator
Elbow surgery
Gallbladder surgery
Gastric bypass
Hand surgery
Heart surgery
Hernia repair
Hip replacement
Hip surgery
Hysterectomy
Knee replacement
Knee surgery
Neck surgery
ORIF
Pacemaker
Shoulder Replacement
Shoulder surgery
Thyroidectomy
Tonsillectomy
Tubal ligation
Transplant

Other

Describe any problems with anesthesia:

Allergies

List Allergies and Reactions:

NONE
Latex
Tape
Iodine
Chicken/Egg
Metal
Medication

Allergy #1

Reaction

Allergy #2

Reaction

Allergy #3

Reaction

Medical History

Check symptoms/conditions you currently have or had in the PAST YEAR:

General

Dizziness/Fainting
Headache/Migraine
Loss of weight
Sweats/Fever
Bleeding Disorder
HIV

Gastrointestinal

Poor appetite
Indigestion
Hepatitis
Vomiting blood
Ulcers
Liver Failure

Heent

Blurred Vision
Difficulty Swallowing
Hoarseness
Loss of Hearing
Sinus issues
Glaucoma

Endocrine

Diabetes
Thyroid problems

Psychological

Depression
Anxiety/Nervous
Bipolar

Muscle/Joint/Bone

Gout
Rheumatoid Disease
Bipolar
Osteogenesis imperfection
Osteoporosis

Pain/weakness/numbness of:

Arms
Back
Feet
Hands
Hips
Legs
Neck

Cardiovascular

Chest Pain
Hypertension
Hypotension
Cardiac Arrhythmia
Ankle swelling
Blood Clot
Heart Disease
High Cholesterol
Stent

Skin

Bruise easily
Change in moles
Thick scars
Persistent sores

Pulmonary

Tuberculosis
Emphysema/COPD
Asthma
Sleep Apnea

Cancer

Thyroid
Myeloma
Leukemia
Lung
Bone
Prostate
Breast
Kidney
Skin
Colon

Neurological

Seizure Disorder
Stroke
Neuropathy
Multiple Sclerosis
Polo

Genitourinary

Frequent urination
Lack of bladder control
Painful urination
Prostate problems
Renal Failure

Females: Type of birth control

None Used

None Used

Currently Pregnant?

Yes
No
Unsure

Are there other medical problems/symptoms not listed above?

Have you tested positive for MRSA?

Yes
No
Unknown

Family History

Check illnesses which have occurred in your immediate family:

Arthritis
Bleeding frequency
Diabetes
Anxiety/Nervous Illness
Heart Disease
Stroke

Other

Mother

Alive
Deceased

Cause of Death

Father

Alive
Deceased

Cause of Death

Siblings

Alive
Deceased

Cause of Death

Social History

Occupation

Currently Employed:

Smoker

Current
Former

Packs/day

Year Started

Year Stopped

Chewing Tobacco

Current
Former

Packs/day

Year Started

Year Stopped

Alcohol Intake

None
Occasional
Moderate
Heavy

I certify the above information is correct to the best of my knowledge. I will not hold Midwest Orthopedic Specialists, Inc. or any member(s) of the staff responsible for errors or omissions I may have made.

Electronic Signature *

First

Last

Date *

ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE

I acknowledge that I have received the attached Privacy Notice

Electronic Signature *

First

Last

Date *

Personal Representative’s Electronic Signature (If Applicable)

First

Last