Patient Information: Please Check All That Apply and List Reaction - Hives, Nausea, Anaphylaxis, Etc

__________________________________________________________________________________________
PATIENT INFORMATION
Date: ___________________ Name: _________________________________ DOB: ______/______/________
Height: _____________ feet _____________ inches
Weight: _____________ lbs.
Pharmacy: _______________________________________ Pharmacy Phone #: _________________________

Pharmacy Address: __________________________________________________________________________
__________________________________________________________________________________________
ALLERGIES
Please check all that apply and list reaction hives, nausea, anaphylaxis, etc.
Aspirin/NSAID _______________________
Codeine/Narcotics _______________________
IV Dye/Iodine _______________________
Antibiotics (Name) _______________________
Sulfa _______________________________
Latex __________________________________
Other ______________________________
Other __________________________________
No known drug allergies

__________________________________________________________________________________________
PRESENT MEDICATIONS
Name of Drug
Please list proper name.

Dose
No Medications
Name of Drug
Dose
REVIEW OF SYSTEMS
Do you have any of the following symptoms? Please check all that apply.
Over (Please complete reverse side)
Constitutional
Cardiovascular
Metabolic/Endocrine
Integumentary/Skin
fatigue
chest pain
cold intolerant
rash
fever
cyanosis
heat intolerant
night sweats
irregular heartbeats
Hematologic/Blood
Neurological
bleeding
HEENT
Gastrointestinal
difficulty walking
headache
constipation
dizziness
Immunological
vision loss
diarrhea
environmental allergies
nausea
Psychiatric
food allergies
Respiratory
vomiting
anxiety
cough
depression
dyspnea
Genitourinary
insomnia
dysuria
hematuria
No known conditions apply
__________________________________________________________________________________________
HISTORY OF PRESENT INJURY
Explain the nature of your visit.
Location: Body part _________________
Left
Right
(Circle one that best applies):
pain
numbness
(Circle one):
SUDDENLY
or
Did this occur
When did this begin?

Date: __________________ or
Severity:
Mild
Context:
during sports
Frequency:
Status:
Quality:
unchanged
aching
weakness
GRADUALLY?
Duration of symptoms: __________________ day(s), month(s), year(s)
Mild-Moderate
intermittent
Both
home
Moderate
Moderate-Severe
Severe
MVA
school /work
no injury
occasional
better
burning
fluctuating
dull
constant
improving
piercing
rare
worse
sharp
resolved
throbbing
__________________________________________________________________________________________
PAST MEDICAL HISTORY
Please check all that apply.
Alzheimers disease
High cholesterol
Renal disease
Anemia
Fibromyalgia
Scoliosis
Angina
Fracture
Seizure disorder
Athritis
Gout
Sleep apnea
Asthma
Headache, migraine
Spinal stenosis
Cancer
Hepatitis/liver disease
Spondyloarthopathy
Congestive heart failure
Hypertension
Stroke
COPD
Inflammatory bowel disease
Systemic lupus erythematosus
Coronary artery disease
Lyme disease
Thyroid disease
Crohns disease
Heart attack
Valvular disease
Deep venous thrombosis
Obesity
GERD
Degenerative joint disease
Osteoporosis
Other
Depression
Parkinson disease
Diabetes
Peptic ulcer disease
Drug abuse
Psoriasis
__________________________________________________________________________________________
PAST SURGICAL HISTORY
Please check all that apply.
ACL repair
Cholecystectomy
ORIF
Amputation
Colectomy
Rotator cuff repair
Angioplasty
Colostomy
Small bowel resection
Appendectomy
Gastric bypass
Thyroidectomy
Arthroscopy
Hernia repair
Tonsillectomy
Back surgery
Hip arthroplasty
Other
Blood transfusion
Hip replacement
CABG
Hysterectomy
Cardiac pacemaker
Knee replacement
Cardiac valve replacement
LASIK
Carpal tunnel release
Mastectomy
Cataract extraction
Meniscus surgery
__________________________________________________________________________________________
FAMILY HISTORY
Is your father living? Yes No If no, age deceased: __________ Cause of death: ____________________
Is your mother living? Yes No If no, age deceased: __________ Cause of death: ___________________
Are any of your brother/sisters deceased? Yes No If yes, age deceased: _______ Cause of death: ________________
Family history of chronic/inherited diseases: _____________________________________________________

__________________________________________________________________________________________
SOCIAL HISTORY
Tobacco Use:
no
yes
former, year quit: ____________
Consume Alcohol:
no
yes, frequency: ______________
Caffeine Use:
no
yes, type: ______________ daily amount _____________________
Todays Date _________________________

GENERAL PATIENT INFORMATION
Patient Name _________________________________________ Date of Birth ____________________Age______________
Parent/Responsible Party_______________________________________________ Parent SS#________________________
Patient SS#______________________________________________
Address____________________________________________________Apt# _______________________________________
City____________________________________________ State _______________________ Zip_______________________
Home Phone__________________________________ Cell Number______________________________________________
Work Phone___________________________________ E-mail address___________________________________________
Marital Status (circle one)
Single
Race ________________________
Married
Widowed
Separated
Divorced
Preferred language__________________________________
Sex - Male /Female
Occupation________________________________ Employment Status (circle one) Employed F/T Student P/T Student
Employer/School_______________________________________________________________________________________
Employer/School Address________________________________________________________________________________
Who referred you? ______________________________________________________________________________________

Family Physician________________________________________________________________________________________
Address_______________________________________________________________________________________________
Phone_____________________________________________ Do you want a report sent to your primary physician? Y N
EMERGENCY CONTACT INFORMATION

Name/Relationship _____________________________________________________________________________________
Primary Phone __________________________________ Secondary Phone ________________________________________
INSURANCE INFORMATION
Type of Coverage (Circle One): Health
Date of Injury
Workers Comp
Auto Accident
Slip & Fall
None/Self Pay
____________________________________ State Accident Occurred: (MVA only) ______________________
Primary Insurance__________________________________________________________________________________________
Claim/ID Number______________________________ Group Number _______________________________________________
Insurance Address/Zip_________________________________________________________ Phone________________________
Adjustors Name_____________________________________
Adjustors Phone_______________________________
Policy Holder Name_______________________________
Adjustors Fax _______________________________
Relationship
Self
Spouse
Parent
Other
Birth Date____________________________________________ SS #____________________________________________

Address______________________________________________ Phone__________________________________________
Responsible Party/Employer_____________________________________________________________________________
Supervisor Name______________________________________________________________________________________
Address_____________________________________________________________________________________________
MEDICARE PATIENTS ONLY
Secondary Insurance__________________________________________________________________________________
Claim/ID Number_________________________ Group Number _______________________________________________
Insurance Address/Zip_____________________________________________Phone________________________________
Policy Holder Name_______________________________________
Relationship:
Self
Spouse
Parent
Other
Birth Date_______________________________________SS#_________________________________________________
Authorization for Release of Information and Direct Payment to the Doctor

DIRECT PAYMENT: I authorize and direct my Insurance Carrier(s) to make payments for medical or surgical treatment,
injections, supplies and x-rays directly to Premier Orthopaedic & Sports Medicine Associates, Ltd. I hereby authorize the
submission of all information necessary to complete this claim. These authorizations shall be effective for me and my
dependents. I agree that a copy of this authorization shall be as valid as the original.
MEDICARE and MEDIGAP: I request that payment of authorized MEDICARE AND MEDIGAP benefits be made either to me or
on my behalf to the physician named below for services furnished by the physician. I authorize any holder of medical
information about me to release to the Health Care Financing Administration and its agents to my MEDIGAP insurer and any
information needed to determine these benefits or the benefits payable for the related services.
I understand and agree that I am responsible for payment of all charges not fully paid by my insurance.
Patient Signature____________________________________________________
Date ___________________
Acknowledgement of Notice
I acknowledge receipt of Chester County Premier Orthopaedic Associates, LTD. Notice of Privacy Practices.
Patients Name: _______________________________________________
Date: ____________________
Patients Signature: ___________________________________________
For purposes of rendering treatment or communications about payment of medical bills, will you permit us to
release financial or medical records to another party?
YES
NO
If yes, please give name and relationship below. (EX: family member, friend, etc)
Print Name/Relationship to patient: _________________________________________________________
Print Name/Relationship to patient: _________________________________________________________
(STAFF USE) Good Faith Effort Made: _____________________________ Date: _____________

Patient Information: Please Check All That Apply and List Reaction - Hives, Nausea, Anaphylaxis, Etc

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__________________________________________________________________________________________

Weight: _____________ lbs.

Pharmacy: _______________________________________ Pharmacy Phone #: _________________________

Antibiotics (Name) _______________________

No known drug allergies

Please list proper name.

Explain the nature of your visit.

Location: Body part _________________

(Circle one that best applies):

Did this occur

When did this begin?

Duration of symptoms: __________________ day(s), month(s), year(s)

PAST MEDICAL HISTORY

Please check all that apply.

Please check all that apply.

Family history of chronic/inherited diseases: _____________________________________________________

Todays Date _________________________

Marital Status (circle one)

Sex - Male /Female

Who referred you? ______________________________________________________________________________________

EMERGENCY CONTACT INFORMATION

Slip & Fall

____________________________________ State Accident Occurred: (MVA only) ______________________

Policy Holder Name_______________________________

Adjustors Fax _______________________________

Birth Date____________________________________________ SS #____________________________________________

Authorization for Release of Information and Direct Payment to the Doctor

Patients Signature: ___________________________________________

Print Name/Relationship to patient: _________________________________________________________

Print Name/Relationship to patient: _________________________________________________________

(STAFF USE) Good Faith Effort Made: _____________________________ Date: _____________

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Pharmacy: _______________ Pharmacy Phone #: _

______________ State Accident Occurred: (MVA only)

Birth Date SS #

(STAFF USE) Good Faith Effort Made: _________________ Date: _