rheumatology - dr. mary olsen, md
TRANSCRIPT
Today’s Date:__________________________________________________
Name: ________________________________________________________
Mailing Address:________________________________________________
City, State, Zip: _________________________________________________
In case of Emergency, Notify: _____________________________________
Phone: ________________________________________________________
Relationship to patient: ___________________________________________
Sex: Male ( ) Female ( )
Referred by: ____________________________________________________
Phone: ________________________________________________________
Insurance Information
Primary Insurance: _______________________________________________
Mailing Address: ________________________________________________
City, State, Zip: _________________________________________________
Name/Policy Holder: _____________________________________________
SSN: __________________________________________________________
Secondary Insurance: _____________________________________________
Mailing Address: ________________________________________________
City, State, Zip: _________________________________________________
Name/Policy Holder: _____________________________________________
SSN: __________________________________________________________
Employment Information
Employer: _____________________________________________________
Mailing Address: _______________________________________________
Telephone: ____________________________________________________
City, State, Zip: _________________________________________________
Responsible Party Information
Name: ________________________________________________________
Mailing Address: ________________________________________________
City, State, Zip: _________________________________________________
SSN: __________________________________________________________
Account #_____________________
Marital Status: Married ( ) Single ( ) Widowed ( ) Divorced ( )Home Phone: ________________________ Cell Phone: _________________
Age: _________ E-Mail: ________________________________________
DOB: _____________ Preferred Language: _______________________
ID Number: ________________________ Group Number: _______________ ID Number: ________________________ Group Number: _______________
DOB: __________ Relationship to Patient: __________________________ DOB: __________ Relationship to Patient: __________________________
DOB: __________ E-Mail: _______________________________________
Payment of Benefits I authorize payment of benefits, as determined by the insurance company, directly to the physician’s office. I understand that I still may be responsible for any amounts not paid by my insurance company. Signature: ____________________________________________________________________ Date: ___________________________________ Medical Release Authorization I authorize any insurance company, organization, employer, hospital, physician, dentist, or pharmacist to release any information requested with regard to processing my claim. I certify that all information on this form is true and correct to the best of my knowledge. I know it is a crime to fill out this form with facts I know are false or to leave out facts I know are important. Signature: ____________________________________________________________________ Date: ___________________________________ Cancellation of Scheduled Appointments I understand that if I have a serious emergency and I am unable to come to my appointment, I will contact the office as soon as possible. In other cases, if I fail to cancel my appointment 24 business hours in advance, I will be charged $50.00 for the missed appointment. Signature: _____________________________________________________________________ Date: __________________________________
As the responsible party, I agree that all charges that are not directly paid by the insurance company will be my responsibility X ____________________________________________________________ Responsible Party Signature Phone: ________________________________________________________
New Patient Registration Form Rheumatology - Dr. Mary Olsen, MD
SSN: _____________________ Preferred Pharmacy: ____________________
Date of first appointment: / /month day year
Time of appointment: _______________________ Birthplace: ____________________________________________
Name: last first middle initial maiden
Birthdate: / /month day year
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Date symptoms began (approximate): ______________________________________________________ Diagnosis: _____________________________________________________________________________________________________
Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later):
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
RHEUMATOLOGIC (ARTHRITIS) HISTORYAt any time have you or a blood relative had any of the following? (check if “yes”)
Yourself Relative Name/Relationship Yourself Relative
Name/RelationshipArthritis (unknown type) Lupus or “SLE”
Osteoarthritis Rheumatoid Arthritis
Gout Ankylosing Spondylitis
Childhood Arthritis Osteoporosis
Other arthritis conditions: ________________________________________________________________________________________________________________________________________________________________________________________________________________
Patient’s Name: ____________________________________________________________________ Date: _________________________________________________________ Physician Initials: ___________
Patient History Form © 2016 American College of Rheumatology
Patient History Form
Please shade all the locations of your pain over the past week on the body figures and hands.Example:
LEFT RIGHT LEFT
LEFT RIGHT
Adapted from CLINHAQ, Wolfe F and Pincus T. Current Comment – Listening to the patient – A practical guide to self report questionnaires in clinical care. Arthritis Rheum. 1999;42 (9): 1797-808. Used by permission.
Referred here by: (check one) Self Family Friend Doctor Other Health Professional
Name of person making referral: __________________________________________________________________________________________________________________________________________________________________________________________________
The name of the physician providing your primary medical care:___________________________________________________________________________________________________________________________________________
Describe briefly your present symptoms: ___________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Please list the names of other practitioners you have seen for this problem:
SYSTEMS REVIEW
As you review the following list, please check any problems, which have significantly affected you:
Date of last mammogram: / / Date of last eye exam: / / Date of last chest x-ray: / /
Date of last Tuberculosis Test / / Date of last bone densitometry / /
Constitutionalq Recent weight gain
amount _________________________________________________________
q Recent weight loss amount _________________________________________________________
q Fatigueq Weaknessq Feverq Eyesq Painq Rednessq Loss of visionq Double or blurred visionq Drynessq Feels like something in eyeq Itching eyes
Ears-Nose-Mouth-Throatq Ringing in earsq Loss of hearingq Nosebleedsq Loss of smellq Dryness in noseq Runny noseq Sore tongueq Bleeding gumsq Sores in mouthq Loss of tasteq Dryness of mouthq Frequent sore throatsq Hoarsenessq Difficulty swallowing
Cardiovascularq Chest Painq Irregular heart beatq Sudden changes in heart beatq High blood pressureq Heart murmurs
Respiratoryq Shortness of breathq Difficulty breathing at nightq Swollen legs or feetq Coughq Coughing of bloodq Wheezing (asthma)
Gastrointestinalq Nauseaq Vomiting of blood or coffee ground
materialq Stomach pain relieved by food or milkq Jaundiceq Increasing constipationq Persistent diarrheaq Blood in stoolsq Black stoolsq Heartburn
Genitourinaryq Difficult urinationq Pain or burning on urinationq Blood in urineq Cloudy, “smoky” urineq Pus in urineq Discharge from penis/vaginaq Getting up at night to pass urineq Vaginal drynessq Rash/ulcersq Sexual difficultiesq Prostate trouble
For Women Only:Age when periods began: _____________________________
Periods regular? q Yes q NoHow many days apart? __________________________________
Date of last period? / /Date of last pap? / /Bleeding after menopause? q Yes q NoNumber of pregnancies? _______________________________
Number of miscarriages? ______________________________
Musculoskeletalq Morning stiffness
Lasting how long? ______________________Minutes ______________________Hours
q Joint painq Muscle weaknessq Muscle tendernessq Joint swelling
List joints affected in the last 6 mos.____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Integumentary (skin and/or breast)q Easy bruisingq Rednessq Rashq Hivesq Sun sensitive (sun allergy)q Tightnessq Nodules/bumpsq Hair lossq Color changes of hands or feet in
the cold
Neurological Systemq Headachesq Dizzinessq Faintingq Muscle spasmq Loss of consciousnessq Sensitivity or pain of hands and/or feetq Memory lossq Night sweats
Psychiatricq Excessive worriesq Anxietyq Easily losing temperq Depressionq Agitationq Difficulty falling asleepq Difficulty staying asleep
Endocrineq Excessive thirst
Hematologic/Lymphaticq Swollen glandsq Tender glandsq Anemiaq Bleeding tendencyq Transfusion/when _______________________________________
Allergic/Immunologicq Frequent sneezingq Increased susceptibility to infection
Patient’s Name: ____________________________________________________________________ Date: _________________________________________________________ Physician Initials: ________________________
Patient History Form © 2016 American College of Rheumatology
SOCIAL HISTORY
Do you drink caffeinated beverages?
Cups/glasses per day? ___________________________________________________________________________
Do you smoke? q Yes q No q Past – How long ago? __________________
Do you drink alcohol? q Yes q No Number per week _________________
Has anyone ever told you to cut down on your drinking?
q Yes q No
Do you use drugs for reasons that are not medical? q Yes q NoIf yes, please list: _______________________________________________________________________________
____________________________________________________________________________________________________________________
Do you exercise regularly? q Yes q NoType _____________________________________________________________________________________________________
Amount per week _____________________________________________________________________________________
How many hours of sleep do you get at night? __________________________________
Do you get enough sleep at night? q Yes q No
Do you wake up feeling rested? q Yes q No
PAST MEDICAL HISTORYDo you now have or have you ever had: (check if “yes)
q Cancer
q Goiter
q Cataracts
q Nervous breakdown
q Bad headaches
q Kidney disease
q Anemia
q Emphysema
q Heart problems
q Leukemia
q Diabetes
q Stomach ulcers
q Jaundice
q Pneumonia
q HIV/AIDS
q Glaucoma
q Asthma
q Stroke
q Epilepsy
q Rheumatic fever
q Colitis
q Psoriasis
q High Blood Pressure
q Tuberculosis
Other significant illness (please list) _____________________________________________________
_____________________________________________________________________________________________________________________
Natural or Alternative Therapies (chiropractic, magnets, massage, over-the-counter preparations, etc.)
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
PREVIOUS SURGERIESType Year Reason
1.
2.
3.
4.
5.
6.
7.
Any previous fractures? q No q Yes Describe: ___________________________________________________________________________________________________________________________________________________________________
Any other serious injuries? q No q Yes Describe: _____________________________________________________________________________________________________________________________________________________________
FAMILY HISTORY
IF LIVING IF DECEASED
Age Health Age at Death Cause
Father
Mother
Number of siblings _______________________ Number living ________________________ Number decreased ______________________
Number of siblings _______________________ Number living ________________________ Number decreased ______________________ List ages of each____________________________________________________
Health of children _______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you know any blood relative who has or had: (check and give relationship)
q Cancer ______________________________________
q Leukemia __________________________________
q Stroke ________________________________________
q Colitis ________________________________________
q Heart disease __________________________
q High blood pressure _______________
q Bleeding tendency __________________
q Alcoholism _______________________________
q Rheumatic fever ______________________
q Epilepsy ____________________________________
q Asthma _____________________________________
q Psoriasis ___________________________________
q Tuberculosis ______________________________
q Diabetes _____________________________________
q Goiter __________________________________________
Patient’s Name: ____________________________________________________________________ Date: _________________________________________________________ Physician Initials: ________________________
Patient History Form © 2016 American College of Rheumatology
MEDICATIONSDrug allergies: q No q Yes If yes, please list: _________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Type of reaction: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________
PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.)Name of Drug Dose (include
strength & number of pills per day)
How long have you taken this
medication
Please check: Helped?
A Lot Some Not At All
1. q q q
2. q q q
3. q q q
4. q q q
5. q q q
6. q q q
7. q q q
8. q q q
9. q q q
10. q q q
PAST MEDICATIONS: Please review this list of “arthritis” medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided.
Drug names/DoseLength of
timePlease check: Helped?
A Lot Some Not At AllReactions
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) q q q
Circle any you have taken in the past
Flurbiprofen Diclofenac + misoprostil Aspirin (including coated aspirin) Celecoxib Sulindac
Oxaprozin Salsalate Diflunisal Piroxicam Indomethacin Etodolac Meclofenamate
Ibuprofen Fenoprofen Naproxen Ketoprofen Tolmetin Choline magnesium trisalcylate Diclofenac
Pain RelieversAcetaminophen q q q
Codeine q q q
Propoxyphene q q q
Other: q q q
Other: q q q
Disease Modifying Antirheumatic Drugs (DMArDS)Certolizumab q q q
Golimumab q q q
Hydroxychloroquine q q q
Penicillamine q q q
Methotrexate q q q
Azathioprine q q q
Sulfasalazine q q q
Quinacrine q q q
Cyclophosphamide q q q
Cyclosporine A q q q
Etanercept q q q
Infliximab q q q
Tocilizumab q q q
Other: q q q
Other: q q q
Patient’s Name: ____________________________________________________________________ Date: _________________________________________________________ Physician Initials: ________________________
Patient History Form © 2016 American College of Rheumatology
PAST MEDICATIONS Continued
Drug names/DoseLength of
timePlease check: Helped?
ReactionsA Lot Some Not At All
Osteoporosis MedicationsEstrogen q q q
Alendronate q q q
Etidronate q q q
Raloxifene q q q
Fluoride q q q
Calcitonin injection or nasal q q q
Risedronate q q q
Other: q q q
Other: q q q
Gout MedicationsProbenecid q q q
Colchicine q q q
Allopurinol q q q
Other: q q q
Other: q q q
OthersTamoxifen q q q
Tiludronate q q q
Cortisone/Prednisone q q q
Hyaluronan q q q
Herbal or Nutritional Supplements q q q
Please list supplements:
Have you participated in any clinical trials for new medications? q Yes q NoIf yes, list:
Patient’s Name: ____________________________________________________________________ Date: _________________________________________________________ Physician Initials: ________________________
Patient History Form © 2016 American College of Rheumatology
ACTIVITIES OF DAILY LIVING
Do you have stairs to climb? q Yes q No If yes, how many?
How many people in household? ____________________________________Relationship and age of each ________________________________________________________________________________________________________
Who does most of the housework? _________________________ Who does most of the shopping? _______________________ Who does most of the yard work? ____________________
On the scale below, circle a number which best describes your situation; Most of the time, I function…
1 2 3 4 5
VERY POORLY OK WELL VERYPOORLY WELL
Because of health problems, do you have difficulty: (Please check the appropriate response for each question.) Usually Sometimes NoUsing your hands to grasp small objects? (buttons, toothbrush, pencil, etc.) ............................................................. q q q
Walking? ....................................................................................................................................................................... q q q
Climbing stairs? ............................................................................................................................................................ q q q
Descending stairs? ....................................................................................................................................................... q q q
Sitting down? ................................................................................................................................................................ q q q
Getting up from chair? ................................................................................................................................................. q q q
Touching your feet while seated? ................................................................................................................................. q q q
Reaching behind your back? ....................................................................................................................................... q q q
Reaching behind your head? ....................................................................................................................................... q q q
Dressing yourself? ....................................................................................................................................................... q q q
Going to sleep? ............................................................................................................................................................ q q q
Staying asleep due to pain? ......................................................................................................................................... q q q
Obtaining restful sleep? ............................................................................................................................................... q q q
Bathing? ....................................................................................................................................................................... q q q
Eating? ......................................................................................................................................................................... q q q
Working? ...................................................................................................................................................................... q q q
Getting along with family members? ............................................................................................................................ q q q
In your sexual relationship?.......................................................................................................................................... q q q
Engaging in leisure time activities? .............................................................................................................................. q q q
With morning stiffness ................................................................................................................................................. q q q
Do you use a cane, crutches, walker or wheelchair? (circle one) ............................................................................... q q q
What is the harde st thing for you to do?__________________________________________________________________________________________________________________________________________________________________________________
Are you receiving disability? ...................................................................................................................................Yes q No q
Are you applying for disability? ...............................................................................................................................Yes q No q
Do you have a medically related lawsuit pending? .................................................................................................Yes q No q
Patient’s Name: ____________________________________________________________________ Date: _________________________________________________________ Physician Initials: ________________________
Patient History Form © 2016 American College of Rheumatology
St Thomas Location:
9149 Estate Thomas, Ste 104
St. Thomas, VI 00802
PH: 340.714.2845
FX: 340.714.2843
St Croix Location:
4423 Estate Mary’s Fancy
Christiansted, VI 00820
PH: 340.692.5000
FX: 340.692.5002
Cardiology | Orthopaedics | Pain Management | Rheumatology
Rehabilitation | Wellness | Wound Care
Cancellation Policy/No Show Policy
For Doctor Appointments and Surgery
1. Cancellation/ No Show Policy for Appointment
We understand that there are times when you must miss an appointment due to emergencies or
obligations for work or family. However, when you do not call to cancel an appointment, you may
be preventing another patient from getting much needed treatment. Conversely, the situation may
arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a
seemingly “full” appointment book. If an appointment is not cancelled at least 24 hours in advance
you will be charged a fifty-dollar ($50) fee; this will not be covered by your insurance company.
2. Scheduled Appointments
We understand that delays can happen however we must try to keep the other patients and doctors
on time. If a patient is 15 minutes past their scheduled time we may have to reschedule the
appointment.
3. Cancellation/ No Show Policy for Surgery
Due to the large block of time needed for surgery, last minute cancellations can cause problems and
added expenses for the office. If surgery is not cancelled at least 10 days in advance you will be
charged a two hundred dollar ($200) fee; this is will not be covered by your insurance company.
4. Account balances
We will require that patients with self-pay balances do pay their account balances to zero (0) prior
to receiving further services by our practice. Patients who have questions about their bills or who
would like to discuss a payment plan option may call and ask to speak to a business office
representative with whom they can review their account and concerns. Patients with balances over
$100 must make payment arrangements prior to future appointments being made.
______________________ _______________________ ____/____/____
Print Name Patient Signature Patient/Guardian Date
Patient Account #___________________
(Office Use Only)