New Patient or New Problem Visit Information

First Name

Please complete this field.

Last Name

Please complete this field.

Date of Birth:

Please complete this field.

Chart:

Please complete this field.

Date:

Please complete this field.

Age:

Please complete this field.

Reason for Today's Visit:

Please complete this field.

(which side? Right, left both)

Please complete this field.

When did the problem begin?

Please complete this field.

Date of Injury:

Please complete this field.

Was it related to an accident?

Yes

Please select an option.

Please list anything that aggravates the problem:

Please complete this field.

Choose your pain levels (0=no pain and 10=terrible pain)

Since the start of the problem, are you:

Improving

Getting Worse

Staying the Same

Please select an option.

Please list anything, including treatments, that help relieve the problem:

Please complete this field.

Whom have you seen for this problem?

Please complete this field.

What test(s) have been done? When? Where?

X-Ray

Please complete this field.

MRI

Please complete this field.

CT Scan

Please complete this field.

Bone Scan

Please complete this field.

Other

Please complete this field.

What treatments have you had for this problem?

Please complete this field.

Medications:

Please complete this field.

Physical Therapy:

When?

Please complete this field.

How many visits?

Please complete this field.

Injections (type/date)

Please complete this field.

Surgery (type/date)

Please complete this field.

Other

Please complete this field.

Last date worked?

Please complete this field.

Employer at the time of this injury:

Please complete this field.

How long have you worked for this company?

Please complete this field.

# of hours work(ed) per week

Please complete this field.

Current Employer:

Please complete this field.

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of the staff responsible for any errors or omissions that I may have made in the completion of this form.

HEALTH HISTORY

Please complete the following information for review by your provider.

Height:

Please complete this field.

Weight:

Please complete this field.

Race:

Please complete this field.

Sex:

Please complete this field.

Referring Doctor:

Please complete this field.

Family Doctor:

Please complete this field.

Occupation:

Please complete this field.

Patient Medical History

Heart Trouble

High Blood Pressure

Stroke

Diabetes

Arthritis

Gout

Seizures

Sleep Apnea

Osteoporosis

Bleeding Problems

Serious Injuries

Lung Disease

Asthma

Phlebitis

Anemia

Stomach Ulcers

Liver Trouble

Thyroid Trouble

Cancer

AIDS/HIV

Hepatitis

Other:

Please complete this field.

Previous Surgeries:

Please complete this field.

Hospital/Date:

Please complete this field.

Previous Surgeries:

Please complete this field.

Hospital/Date:

Please complete this field.

Previous Surgeries:

Please complete this field.

Hospital/Date:

Please complete this field.

Previous Surgeries:

Please complete this field.

Hospital/Date:

Please complete this field.

Previous Surgeries:

Please complete this field.

Hospital/Date:

Please complete this field.

Previous Surgeries:

Please complete this field.

Hospital/Date:

Please complete this field.

No Previous Surgeries

Family Medical History (Mark if any of these run in your family)

Heart Trouble

High Blood Pressure

Stroke

Diabetes

Arthritis

Gout

Kidney Trouble

Bleeding

Alcoholism

Cancer

Social History

Married

Single

If no, who do you live with?

Please complete this field.

# of children:

Please complete this field.

Describe:

Please complete this field.

Type:

Please complete this field.

Amount per day

Please complete this field.

# of years used:

Please complete this field.

Type/Amount/How Often:

Please complete this field.

Review of Systems (recent or current conditions only)

Weight Change

Fever/Chills

Night Sweats

Poor Appetite

Rash

Insomnia

Depression

Anxiety

Ear Pain / Ringing

Nosebleeds

Hoarseness

Tooth/Gum Trouble

Visual Changes

Chest Pain

Abnormal Heartbeat

Shortness of Breath

Cough

Stomach Pain

Nausea/Vomiting

Frequent Diarrhea

Frequent Constipation

Blood in Stool

Incontinence

Urinary Frequency

Urinary Burning

Irregular Periods

Vaginal Discharge

Pregnant

Joint/Limb Swelling

Joint Pain

Lumps/Masses

Backache

Numbness

Weakness

Frequent Headaches

Seizures

Blackouts

Chronic Infection

Other:

Please complete this field.

MEDICATION RECORD

Please complete the following information for review by your provider.

Allergies to Medications:

None

Yes, list down

Please select an option.

Medication

Please complete this field.

Allergic Reaction

Please complete this field.

Medication

Please complete this field.

Allergic Reaction

Please complete this field.

Medication

Please complete this field.

Allergic Reaction

Please complete this field.

Medication

Please complete this field.

Allergic Reaction

Please complete this field.

Medication

Please complete this field.

Allergic Reaction

Please complete this field.

List any food allergies and reaction:

Please complete this field.

None

Medications you currently take (including over the counter medications, vitamins, herbs, & prescribed drugs):

See separate medication list

Date

Please complete this field.

Medication

Please complete this field.

Dosage/Frequency

Please complete this field.

For Surgery Center Use Only

Please complete this field.

Date

Please complete this field.

Medication

Please complete this field.

Dosage/Frequency

Please complete this field.

For Surgery Center Use Only

Please complete this field.

Date

Please complete this field.

Medication

Please complete this field.

Dosage/Frequency

Please complete this field.

For Surgery Center Use Only

Please complete this field.

Date

Please complete this field.

Medication

Please complete this field.

Dosage/Frequency

Please complete this field.

For Surgery Center Use Only

Please complete this field.

Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Date

Please complete this field.

Subscribe to updates from Mountainstate Orthopedic Associates, Inc.