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... pain free.
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Home
About Us
Our Team
- Dr. Curtis D. Burton
- Dr. Richard L. Baumann
- Dr. Rahul Basho
Areas of Practice
- Sprains
- Neck & Back
- Carpal Tunnel
- Fractures
- Shoulder
- Knee
- Elbow
- Hip
Patient Toolbox
- Pay Your Bill
- Patient Portal
- What to Bring to the Hospital
- Insurance Information
- Helpful Links
- Patient Forms
- - Request for Release of Records
News & Press
- Videos/Testimonials
- Success Stories
Patient Education
- Easing the Pain
- Understanding Arthritis
- Vacationing with Arthritis
- Guide to Hips
- Guide to Elbows
- Guide to Knees
- Guide to Shoulders
- Diet Tips
- Helpful Exercises
- Osteoarthritis
Contact Us
Home
About Us
Our Team
Dr. Curtis D. Burton
Dr. Richard L. Baumann
Dr. Rahul Basho
Areas of Practice
Sprains
Neck & Back
Carpal Tunnel
Fractures
Shoulder
Knee
Elbow
Hip
Patient Toolbox
Pay Your Bill
Patient Portal
What to Bring to the Hospital
Insurance Information
Helpful Links
Patient Forms
Request for Release of Records
News & Press
Videos/Testimonials
Success Stories
Patient Education
Easing the Pain
Understanding Arthritis
Vacationing with Arthritis
Guide to Hips
Guide to Elbows
Guide to Knees
Guide to Shoulders
Diet Tips
Helpful Exercises
Osteoarthritis
Contact Us
Patient Information
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Step
1
of 13
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
Email
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 #
Next
Emergency Contact
Emergency Contact Name
*
First
Last
Relationship
Home Phone
Work Phone
Previous
Next
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
Previous
Next
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?
Yes
No
Electronic Signature
*
First
Last
Date
Previous
Next
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?
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?
Yes
No
Previous
Next
Providers
Primary Care:
Referred By:
Specialty Providers:
Previous
Next
Pharmacy
Preferred Pharmacy
Location
Previous
Next
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:
Previous
Next
Allergies
List Allergies and Reactions:
NONE
Latex
Tape
Iodine
Chicken/Egg
Metal
Medication
Allergy #1
Reaction
Allergy #2
Reaction
Allergy #3
Reaction
Previous
Next
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
Previous
Next
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
Previous
Next
Social History
Occupation
Currently Employed:
Yes
No
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
*
Previous
Next
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
Comment
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