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PLEASE COMPLETE IN INKToday’s Date: Patient Account #: PATIENT NAME: Referring Physician: Primary Care Physician: Other Treating Physicians: Athletic Trainer / School: (if a high school or collegiate athlete)
Date of Birth: Age: Height: Weight:
MEDICAL HISTORY: smelborP lacideM oN Peripheral Vascular Disease
DEXA Scan or Bone Density Scan Hiatal Hernia/Reflux Disease History of MRSA Peptic Ulcer Disease
Claustrophobic or fearful of enclosed spaces Diverticulitis gniriuqeR-nilusnI ,setebaiD Urinary Tract Infections nilusnI-noN ,setebaiD Kidney Stones r and/or Factor V, Factor VIII deficiencyedrosiD gnideelB High Cholesterol
Pulmonary Embolism (Blood Clot Lung) Osteoporosis Deep Vein Thrombosis (Blood Clot Leg) Fibromyalgia
Thyroid Disorder Seizure Disorder SDIA ro VIH Gout amohpmyL ro aimekueL Osteoarthritis tnalpsnarT nagrO Rheumatoid Disease kcattA traeH Migraine Headaches Coronary Artery Disease / Heart Disease Cancer (type) aimhtyhrrA traeH Hepatitis rekamecaP Liver Disease rumruM traeH Psoriasis or Other Skin Disease ekortsiniM ro ekortS Poliomyelitis erusserP doolB hgiH Psychiatric Disorder amhtsA Anxiety Disorder DPOC ro amesyhpmE Depression ainomuenP Drug Addiction sisolucrebuT
Malignant Hyperthermia Glaucoma Dialysis / Renal Failure Reflex Sympathetic Dystrophy (CRPS)
Please list any other conditions not mentioned above:
PAST SURGICAL HISTORY: Please list any operations you have had in the past & date or approximate age at time of procedure
Date or Age No Previous Surgery
Fracture without Surgery Fracture with Surgery Shoulder Surgery Hand Surgery
Spine Surgery
Foot/Ankle Surgery Knee Surgery
Total Hip Arthroplasty
Heart Related Surgery Total Knee Arthroplasty
ymotcedneppA
noitceS-C Gall Bladder
riapeR ainreH ymotceretsyH
Tonsillectomy/Adenoidectomy
Please list any additional surgeries:
egA ro etaD noitarepO
250 Cetronia Road • Allentown, PA 18104 • Phone: 610-973-6200 • www.oaaortho.comLehighton: 1241 Blakeslee Blvd. Dr. E. ● Lehighton, PA 18235 ● 570-386-9910
Bethlehem: 2901 Emrick Blvd. ● Bethlehem, PA 18020 ● 610-973-6200
FAMILY HISTORY: Do any of these diseases run in your immediate family - Mother (M) Father (F) Sister (S) Brother (B)? Mark box and indicate relationship. No Medical Conditions M F S B Heart Disease M F S B
Rheumatoid Arthritis M F S B
Asthma M F S B High Blood Pressure M F S B
Stroke M F S B
Back Problems M F S B Cancer M F S B Diabetes Insulin Dependent M F S B Diabetes Non-Insulin Dependent M F S B
Orthopaedic Problems M F S B
Other
Abused Prescription Drugs Used Recreational Drugs Used Anabolic Steroids Used Other Performance Enhancing Substances
SOCIAL HISTORY: Marital Status: Married Single Divorced Separated Widowed Domestic Partner Number of children?
Do you smoke? Yes No If yes, how many packs a day? If yes, age started
?dekoms ylsuoiverp tnuoma & tiuq uoy did nehw ,rekoms tsap a era uoy fI
Do you use chewing tobacco? Yes No ?sraey ynam woH ?sehcuop/snit ynam woh ,sey fI
Do you use alcohol? No Occasional Moderate
Heavy
Do you use caffeine? No Occasional Moderate
Heavy
Do you exercise? No Occasional Moderate
Heavy
Recreational Activities (sports, hunting, fishing, gardening hobbies, etc.)
Education Less than 8th Grade 8th Grade 9th Grade 10th Grade
11th Grade 12th Grade 2 Year College 4 Year College Post Graduate
OCCUPATIONAL HISTORY:
Employer: What is your primary occupation (if not working, what was your primary occupation)? How many years have you been with your current employer? If not working, how long has it been since you stopped?
What statement describes your current employment situation (check all that apply)? Retired (not due to health) Currently Working Unemployed Homemaker On Unpaid Leave On Paid Leave Disabled
Is there litigation in process pertaining to your symptoms? Yes No
MEDICATIONS:
None
Please list all medications or drugs including birth control pills, over-the-counter medications or herbal supplements you are currently taking
Drug or Medicine Amount/Dose Start Date Stop Date Stop Reason
ALLERGIES: Please list all medications, metals, dyes, latex or foods. If you have a paper list of your medications or allergies, we will make a photocopy of them.
Allergy List Reaction
No Known Drug Allergies
Date:
Patient Name: DOB:
REVIEW OF SYSTEMS: Have you had any of the following in the past six (6) months? Please circle all that apply.
CONSTITUTIONAL (General)Constitutional: fever, night sweats, weight gain (______lbs), weight loss (______ lbs), exercise intolerance
EYESEyes: dry eyes, irritation, vision change
ENMT (Ears, Nose, Mouth, Throat)Ears: difficulty hearing, ear pain Nose: frequent nosebleeds, nose/sinus problems Mouth/Throat: sore throat, bleeding gums, snoring, dry mouth, oral abnormalities, mouth ulcer, teeth abnormalities, mouth breathing
CARDIOVASCULAR Cardiovascular: chest pain on exertion, arm pain on exertion, shortness of breath when walking, shortness of breath when lying down, palpitations, known heart murmur, light-headed on standing
RESPIRATORY Respiratory: wheezing, shortness of breath, coughing up blood, sleep apnea
GASTROINTESTINAL Gastrointestinal: abdominal pain, vomiting, change in appetite, black or tarry stools, frequent diarrhea, vomiting blood
GENITOURINARY Genitourinary: urinary loss of control, difficulty urinating, increased urinary frequency, hematuria (blood),incomplete emptying
MUSCULOSKELETAL Musculoskeletal: muscle aches, muscle weakness, arthralgias/joint pain, back pain
INTEGUMENTARY (Skin) Skin: abnormal mole, jaundice, eczema, rash, itching, dry skin, growths/lesions
NEUROLOGIC Neurologic: loss of consciousness, weakness, numbness, seizures, dizziness, frequent or severe headaches, migraines, restless legs
PSYCHIATRIC Psych: depression, mania, sleep disturbances, restless sleep, feeling unsafe in relationship, alcohol abuse
ENDOCRINE Endocrine: fatigue, increased thirst, hair loss, increased hair growth, cold intolerance
HEMATOLOGIC/LYMPHATIC Hematologic/Lymphatic: swollen glands, easy bruising, excessive bleeding
ALLERGIC/IMMUNOLOGIC Allergy/Immunologic: runny nose, sinus pressure, itching, hives, frequent sneezing
I have had no problems with any body part for the past 6 months.(Stop, no additional info needed.)
None
Patient Name: ________________________________________________ Date:_________________ Age:_________
Where is your pain now?Mark the areas of the body where you feel the sensations described below, using the appropriate symbol.Please include areas where pain radiates and all affected locations.
Ache Numbness Pins and Needles Burning Stabbingss ss ss ss ss = = = = = = oooooooo X X X X / / / / / / /
Place ONE MARK on each line below that indicates your current level of pain.
OA141B
PATIENT PAIN DRAWINGLOW BACK
1. Neck / Back(please circle)
2. Arm / Leg-Right(please circle)
Arm / Leg-Left(please circle)
No Pain Worst Pain Imaginable
No Pain Worst Pain Imaginable
No Pain Worst Pain Imaginable
PLEASE COMPLETE IN INK
1. Date of injury or approximately when pain began: _______/______/_______
2. How did your current episode of pain begin?nn Suddenly nn Gradually
3. What caused your current pain to start?
nn No apparent cause nn Work related injury nn Sports injury nn Fall
nn Lifting nn Pulling nn Bending nn Twisting
nn Car accident nn Motorcycle accident nn Other____________________________
4. Which health care providers have you used for your current condition? (Check all that apply)
nn Chiropractor nn Rheumatologist nn Emergency Dept.
nn Physical therapist nn Massage therapist nn Family physician
nn Internist nn Pain Clinic nn Orthopaedist
nn Neurologist nn Neurosurgeon nn Other____________________________
5. Check all treatments you have had and the effect they had on your pain:
Better Same Worse
nn Bed rest nn nn nn
nn Traction nn nn nn
nn Manipulation nn nn nn
nn Epidural Injection nn nn nn
nn Exercise Therapy nn nn nn
nn Heat nn nn nn
nn Ice nn nn nn
nn Ultrasound nn nn nn
nn Massage nn nn nn
nn TENS unit nn nn nn
nn Pain medication nn nn nn
nn Muscle relaxants nn nn nn
nn Acupuncture nn nn nn
nn Back/Neck brace nn nn nn
nn Other __________________ nn nn nn
6. At this time, which item best describes the ratio between pain in your back and leg? (When we say leg, we meanyour thigh, calf, ankle and foot. When we say back, we mean your back and/or buttocks.)
nn 100% back pain: 0% leg pain
nn 75% back pain: 25% leg pain
nn 50% back pain: 50% leg pain
nn 25% back pain: 75% leg pain
nn 0% back pain: 100% leg pain
7. What aggravates your pain?
nn Lifting nn Bending nn Twisting nn Sitting nn Standing
nn Walking nn Coughing nn Sneezing nn Bowel Movement
nn Exercise nn Fatigue nn Stress/Tension nn Other ______________________________
BACK PAIN QUESTIONNAIRE
8. What relieves your pain?
nn Lying on my back nn Lying on my side nn Lying on my stomach
nn Sitting nn Standing nn Walking nn Exercise
nn Stretching nn Nothing nn Other ________________________________
9. Have you used alcohol to help relieve your pain? nn No nn Yes
10. What are the worst and best times of day for your pain?
Most Pain Least Pain
nn First awakening nn First awakening
nn Morning nn Morning
nn Mid-day nn Mid-day
nn Afternoon nn Afternoon
nn Evening nn Evening
nn Night time nn Night time
11. Does pain interfere with your sleep?
nn No nn Yes, occasionally nn Yes, frequently nn Yes, every night
12. Have you had any of the following symptoms lately?
13. Is your current episode of back and/or leg pain…
nn Getting better nn Staying the same nn Getting worse
14. Do you think the fault for your back condition is: (check all that apply)
nn Nobody’s
nn My own
nn My employer’s
nn A co-worker’s
nn Another person’s
nn Other ______________________________________________________________
15. Have you hired a lawyer because of your back condition?
nn No
nn Yes, and the case is in litigation
nn Yes, and the case has been settled
16. Have you, or are you planning to apply for any of the following programs?
nn Social Security nn Disability nn Workers’ Compensation
nn Other ______________________________________________________________
Fever nn Yes nn No
Night sweats or shaking chills nn Yes nn No
Unexpected weight loss nn Yes nn No
Whole leg goes numb nn Yes nn No
Leg(s) give way causing me to fall nn Yes nn No
Shocking or lightning sensations in my arms or legs nn Yes nn No
Clumsiness with use of hands/dropping things nn Yes nn No
Unsteady walking/difficulty with balance nn Yes nn No
Frequent headaches nn Yes nn No
Dizziness nn Yes nn No
Feel you must urinate and cannot nn Yes nn No
Dribbling nn Yes nn No
Loss of bowel or bladder control nn Yes nn No
1) PAIN INTENSITY
nn I have no pain currently.
nn The pain is very mild at the moment.
nn The pain is moderate at the moment.
nn The pain is fairly severe at the moment.
nn The pain is very severe at the moment.
nn The pain is the worst imaginable at the moment.
2) PERSONAL CARE – (Washing, Dressing, etc.)nn I can look after myself normally without causing
extra pain.
nn I can look after myself normally but it is very painful.
nn It is painful to look after myself and I am slowand careful.
nn I need some help but manage most of mypersonal care.
nn I need help every day in most aspects of self care.
nn I do not get dressed, wash with difficulty and stayin bed.
3) LIFTING
nn I can lift heavy objects without extra pain.
nn I can lift heavy weights but it causes extra pain.
nn Pain prevents me from lifting heavy weights offthe floor, but I can manage if they are convenientlypositioned eg. on a table.
nn Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned.
nn I can lift only very light weights.
nn I cannot lift or carry anything at all.
4) WALKING
nn Pain does not prevent me walking any distance.
nn Pain prevents me walking more than 1 mile.
nn Pain prevents me walking more than 1/4 of a mile.
nn Pain prevents me walking more than 100 yards.
nn I can only walk using a cane or crutches.
nn I am in bed most of the time and have to crawl tothe toilet.
5) SITTING
nn I can sit in any chair as long as I like.
nn I can sit in my favorite chair as long I like.
nn Pain prevents me from sitting for more than 1 hour.
nn Pain prevents me from sitting more than 1/2 an hour.
nn Pain prevents me from sitting for more than10 minutes.
nn Pain prevents me from sitting at all.
6) STANDING
nn I can stand as long as I want without extra pain.
nn I can stand as long as I want but it causes extra pain.
nn Pain prevents me from standing for more than 1 hour.
nn Pain prevents me from standing for more than 1/2 an hour.
nn Pain prevents me from standing for more than10 minutes.
nn Pain prevents me from standing at all.
7) SLEEPING
nn My sleep is never disturbed by pain.
nn My sleep is occasionally disturbed by pain.
nn Because of pain I have less than 6 hours sleep.
nn Because of pain I have less than 4 hours sleep.
nn Because of pain I have less than 2 hours sleep.
nn Pain prevents me from sleeping at all.
8) SEX LIFE (If applicable)
nn My sex life is normal and causes no extra pain.
nn My sex life is normal but causes some extra pain.
nn My sex life is nearly normal but very painful.
nn My sex life is severely restricted by pain.
nn My sex life is nearly absent because of pain.
nn Pain prevents any sex life at all.
9) SOCIAL LIFE
nn My social life is normal and causes no extra pain.
nn My social life is normal but increases the degree ofpain.
nn Pain has no significant effect on my social life apartfrom limiting my more energetic interests, eg. sports.
nn Pain has restricted my social life and I do not go out as often.
nn Pain has restricted my social life to my home.
nn I have no social life because of pain.
10) TRAVELING
nn I can travel anywhere without pain.
nn I can travel anywhere but it causes me extra pain.
nn Pain is bad but I manage journeys of over 2 hours.
nn Pain restricts me to journeys of less than 1 hour.
nn Pain restricts me to short necessary journeys under 30 minutes.
nn Pain prevents me from traveling except to receivetreatment.
OSWESTRY LOW BACK INDEXPlease answer all 10 sections. In each category, check only one that best applies to your current condition.
PATIENT HEALTH QUESTIONNAIRE - PHQ-9Nine Symptom Checklist
Patient Name:______________________________________________________________ Date: ____________________
1. Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not Several More than Nearlyat all days half the days every day
0 1 2 3
a. Little interest or pleasure in doing things nn nn nn nn
b. Feeling down, depressed or hopeless nn nn nn nn
c. Trouble falling/staying asleep, sleeping too much nn nn nn nn
d. Feeling tired or having little energy nn nn nn nn
e. Poor appetite or overeating nn nn nn nn
f. Feeling bad about yourself – or that you are a nn nn nn nnfailure or have let yourself or your family down.
g. Trouble concentrating on things, such as reading nn nn nn nnthe newspaper or watching television.
h. Moving or speaking so slowly that other people nn nn nn nncould have noticed. Or the opposite – being sofidgety or restless that you have been movingaround a lot more than usual.
i. Thoughts that you would be better off dead or of nn nn nn nnhurting yourself in some way.
2. If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to doyour work, take care of things at home, or get along with other people?
nn Not difficult at all nn Somewhat difficult nn Very difficult nn Extremely difficult
3. In the past two years, have you felt depressed or sad most days, even if you felt okay sometimes?
nn Yes nn No
Total # Symptoms:__________________ Total Score:______________________
OAA Patient Request for Confidential Communications Orthopaedic Specialists
Patient: Patient No.: Address:
Soc. Sec.: Phone:
Date of Birth: Please consider this a request for confidential communication of my protected health information (PHI). I understand that you will do your best to reasonably accommodate it.
Check all that apply to this request: Please do not phone me at home. Use the following alternative phone number to contact me:
______________________. Please do not phone me at work. Use the following alternative number to contact me:
______________________. Please send my mail, including my bills, to this alternative address: ________________________________________________________
________________________________________________________ ________________________________________________________
Please do not leave messages on my answering machine/voice mail. Please do not mail appointment cards to me. Please do not contact me by email. Other requests (describe in detail) Please release medical and billing information to:
________________________________________________________ ________________________________________________________ ________________________________________________________
_______ (initial) I understand that the physician or provider to whom I am making this request will make reasonable efforts to accommodate this request. I further understand that in some emergency situations, my PHI may be released. I acknowledge that I have received the Notice of Privacy Practice for OAA-Orthopaedic Specialists. OAA-Orthopaedic Specialists is authorized to use and disclose health information for treatment, payment and healthcare operations purposes consistent with its Notice of Privacy Practices. Note: Please print all information except signature. Patient: Signature of Patient (or patient’s personal representative): ________________________________ Date representative: ________________________________ Name of personal representative: ________________________________ Relationship to patient (or other authority): ________________________________
FINANCIAL POLICY Patient ID#: ___________________
Thank you for choosing OAA Orthopaedic Specialists as your orthopaedic specialty healthcare provider. We are committed to providing you and your family with the best available medical care. In our ongoing process to make sure that all of your medical needs are met, our staff will be available to discuss our fees and this policy with you. The Services you have elected to participate in means that you accept a financial responsibility on your part.
We ask that all responsible parties read and sign our financial policy as well as complete the patient information forms prior to seeing the physician.
Payments for all services will be due at the time services are rendered. In order to serve you better, we accept cash, check, Visa and MasterCard. As a courtesy to you, we will verify your coverage and bill your insurance carrier on your behalf; however, you are ultimately responsible for the entire bill. The only exception to patient responsibility for payment is for an appointment for employer requested work performance screenings. As the responsible party, please understand:
1. Your insurance policy is a contract between you, your employer (if applicable), and the insurance company. We are not a party to that contract. Our relationship is with you, not your insurance company. We will not become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance and “usual and customary” charge. As your medical provider, we will only supply factual information to facilitate claim processing.
2. If your insurance requires a referral for you to see an OAA Orthopaedic Specialists provider, it is your responsibility to provide our office with the referral. If your insurance company denies payment due to no referral, you, the patient, agree to pay OAA Orthopaedic Specialists in full for any charges incurred during your visit.
3. Fees for services, which include unpaid balances, deductibles, co-payments and in some cases coinsurance, are due at the time of service. Returned checks and unpaid balances may be subject to collection placement and collection fees.
4. All charges are your responsibility whether your insurance company pays or does not pay. If your insurance carrier does not remit payment within sixty days, the balance may be due in full from you. If any payment is made directly to you for services billed by OAA Orthopaedic Specialists, you recognize an obligation to promptly remit payment to OAA Orthopaedic Specialists.
5. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, after such default and upon referral to a collection agency or attorney by OAA Orthopaedic Specialists, I will be responsible for all costs of collecting monies owed, including collection agency fees.
6. The above does not apply for those patients that are considered Workers’ Compensation. However, be advised that as a compensation patient you may be held responsible for charges in the event that your claim is denied or not paid or determined not to be work related.
7. Our practice utilizes the services of Assistant Surgeons/Physician Assistants for medical services including surgical procedures. As with the other professional services, we will bill your insurance for these services; however, should your insurance not cover the charges, you may be held ultimately responsible.
8. The completion of disability and/or FMLA forms are not billable/reimbursable by insurance carriers, therefore fees are your responsibility for payment. OAA Orthopaedic Specialists fees related to completion of these documents is $10.00 which is expected to be paid upon presentation of forms for completion. Please allow 10 to 14 business days for completion of these forms.
9. If you need to cancel your scheduled appointment, OAA asks that you contact our office at least 24 hours in advance. OAA reserves the right to apply a $50 fee for any appointment not cancelled within the requested 24 hour timeframe.
We understand that financial problems may affect timely payment, so we encourage you to communicate any such problems to us, so that we may assist you in keeping your account in good standing. Our financial counselor is available to assist you or answer any questions you may have.
INSURANCE RELEASE INFORMATION
I HEREBY AUTHORIZE THE OFFICE OF OAA ORTHOPAEDIC SPECIALISTS TO RELEASE TO MY INSURANCE COMPANY ANY NECESSARY INFORMATION NEEDED TO FILE AND EXPEDITE PAYMENT ON MY CLAIM. I FURTHER ASSIGN ANY BENEFITS PAYABLE ON MY BEHALF TO OAA ORTHOPAEDIC SPECIALISTS. I UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR ANY BALANCE NOT COVERED BY MY INSURANCE CARRIER.
I UNDERSTAND THE ABOVE INFORMATION AND WILL BE RESPONSIBLE FOR THE PATIENT
LISTED BELOW
Printed Name of Patient Date of Birth
Signature of Patient or Responsible Party Date
Relationship if Other than Patient
Your medical provider is participating in a government program that encourages the adoption of electronic health records. This technology will lead to reduced health care costs, but it will also improve the quality of your care and our ability to communicate with you, our patients.
As part of this program, the government requires us to record the following demographic information about you:
Preferred language Race Ethnicity Date of birth Gender
The U.S. Centers for Disease Control and Prevention (CDC) provides the options for the race and ethnicity fields that match the data collection standards defined by the U.S. Office of Management and Budget (OMB) and the U.S. Bureau of the Census (BC). We maintain secure records and assure you that this information will remain confidential.
You can help us by reviewing the list of options below and providing your race and ethnicity information during registration or check-in. If you do not wish to provide this information, you may simply decline.
Thank you for your assistance!
Dear Patients,
Please identify your Race from the following CDC-defined options:
African African American Alaska Native American Indian American Indian
or Alaska Native Arab Asian Asian Indian Bahamian Bangladeshi Barbadian Bhutanese Black
Black or African American
Burmese Cambodian Chinese Dominica Islander Dominican European Fillipino Haitian Hmong Indonesian Iwo Jiman Jamaican
Japanese Korean Laotian Madagascar Malaysian Maldivian Melanesian Micronesian Middle Eastern
or North African Native Hawaiian or
Other Pacific Islander Nepalese Okinawan
Other Pacific Islander
Other Race Pakistani Polynesian Singaporean Sri Lankan Taiwanese Thai Tobagoan Trinidadian Vietnamese West Indian White
Central American Cuban Dominican
Hispanic or Latino/Spanish Latin American/Latin,
Latino
Mexican Not Hispanic or Latino Puerto Rican
South American Spaniard
Please identify your Ethnicity from the following CDC-defined options:
OAA Orthopaedic Specialists
Patient Name: ______________________________________ Date of Birth: _________________
Please specify your preferred language: English Spanish Other ______________