Patient Name: DOB Age M or F
SS# Home Ph# Cell Ph# Work#
Local Address City/State Zip Code
Northern/Other Address City/State Zip Code
Reason for visit If an injury, how did this occur:
Date of Injury Is Injury Auto or Work Related
Referred By: Prim. Care Physician: Phone#:
Employer Name: Occupation
Spouse's Name: Spouse's DOB: Spouse's Wk#:
Nearest Friend or Relative not living with you: Phone#:
Health Ins. Carrier: Auto Ins. Carrier
Attorney's Name Ph #
If Patient Is A Minor, Parent's Name: Parent's Employer
Wk Ph#: In Case Of An Emergency Notify: Phone:
Pharmacy Name Phone #
Patient Email Address
Fm# 1006 03/04 I hereby authorize Orthopedic Specialists of Southwest Florida (hereinafter “OSSWF”) to release any information concerning my care to my insurance company and/or any company under whose policy I am considered an insured and/or omnibus insured. I hereby irrevocably assign all insurance benefits (and/or rights to collect the same) to which I am entitled including, but not limited to, Health Insurance, Personal Injury Protection (PIP), Medical Payments, and/or Medicare benefits, to OSSWF. Moreover, I hereby direct any such insurer to make the necessary payment exclusively and directly to OSSWF in a form payable to OSSWF, only. This irrevocable assignment is given in exchange and/or in consideration for the medical treatment, care, or services rendered to the undersigned by OSSWF.
I___________________________________, and/or my representative agree not to bring frivolous medical malpractice case or cause of action against the physician or physician's legal entity providing care. Furthermore, should a meritorious medical malpractice case or cause of action be initiated or pursued, I _____________________________, and/or my representative agree to use an expert medical witness who adheres to the guidelines and/or code of conduct defined by the specialty society for expert witnesses in the area of medicine who would typically have the background experience to render an opinion on such a case.
New Patient Information Form Orthopedic Specialists Of SW FL
Notwithstanding the granting of this irrevocable assignment, the undersigned agrees to be directly responsible to OSSWF for
ALL bills for services rendered to the undersigned, and this agreement and/or assignment is made solely for OSSWF’s
Orthopedic Specialists Medical History Form Of
Patient's name Date of Birth Age Sex M F
PAST MEDICAL HISTORY - Have you been diagnosed with any of the following medical conditions?
Yes no Yes no Yes no
Heart Disease Yes No Blood Clots/DVT Yes No Rheumatoid Arthritis Yes No
Heart Attack Yes No Bleeding Disorder Yes No Osteoarthritis Yes No
Angina/chest pain Yes No Hypertension Yes No Gout Yes No
Congestive heart failure Yes No Stroke Yes No Thyroid Disease Yes No
COPD/Emphysema Yes No Liver Disease Yes No Tuberculosis Yes No
Asthma Yes No Hepatitis Yes No HIV/AIDS Yes No
Pneumonia Yes No Anemia Yes No Seizures Yes No
Kidney Disease Yes No Sickle Cell Disease Yes No Anxiety Yes No
Renal Failure Yes No Stomach/intestinal ulcers Yes No Depression Yes No
Diabetes Yes No Cancer Yes No Fibromyalgia Yes No
SURGERIES-please list all surgeries with approximate date.
1. 2. 3. 4.
Medications-List all medications with dosage and frequency, (attach list if extensive)
Medication Dosage Frequency
1. 2. 3. 4. 5. 6.
Patient signature Date
Physician Signature Date Medical history form (cont.)
Drug and Food Allergies or adverse Reactions (include penicillin, aspirin, and anti-inflammatory drugs And local anesthesia)
In order to establish a complete understanding of the financial
Marital status: Single Married Divorced Widow(er)
Number of children Presently living alone Yes No
Do you presently smoke tobacco? Yes No
If yes, please list amount you smoke: pack/day packs/week number of years smoked Do you drink alcohol regularly? Yes No
If yes, please amount and type ingested per day Per week What is your occupation?
Family Medical History: (do you have a family history of any of the following illnesses?)
Yes No Yes No Yes No
Cancer Yes No Rheumatoid Arthritis Yes No Heart Disease Yes No
Diabetes Yes No Degenerative Arthritis Yes No Thyroid Disease Yes No
Immune Disorders Yes No Lung Disease Yes No Kidney Disease Yes No
Immunizations: (approximate date or age)
Review of Systems:
Are you currently having or have you had problems with any of the following?
Circle Describe all Yes responses
Musculoskeletal no yes
(reason you are here today; ex. Joint pain, muscle pain, etc.) Weight loss/weight changes no yes
Fever no yes
Eyes, ears, nose, throat no yes
Heart/Cardiovascular no yes Lungs/Respiratory no yes Gastrointestinal no yes Genitourinary no yes Skin no yes Neurological no yes Endocrine no yes Hematologic no yes Psychiatric no yes
I certify that to the best of my knowledge the preceding information is true and accurate.
Patient signature Date
For office use only:
Initial date Initial date
OF SW FLORIDA
Patient Name:___________________________________________ Where is your pain?
Please mark on the drawing below all the areas where you feel your pain. Use an X for pain
Use a ___ for numbness
The Specialized Care of Fellowship-Trained Surgeons
Accident/Injury Detail- (this form must be completed, signed and dated)
Many insurance companies require accident/injury details after they receive our claim. Please answer the following questions and explain how this accident/injury occurred.
Is this claim related to an accident?
NO If not due to any type of accident, please describe your symptoms; when they started, and the manner in which they started.
YES Please answer the following that apply below: Date of Injury:
Location of Injury (home, work, etc.):
If Auto, Motorcycle, slip/fall, or “Other Accident” please answer the following:
Auto Motorcycle ATV/Dirt Bike Bicycle Slip/Fall Other (animal bite, tools, etc.)
Provide description of how accident occurred:
Were you the driver or passenger? Do you own the vehicle? Yes No
If motorcycle related, do you have PIP insurance that would cover medical expenses relating to this accident? Yes No Has a claim been made with your auto insurance carrier? Yes No
If Work related, please answer the following:
Name of employer at the time of injury: Are you self employed? Yes No
Do you receive a W-2 (employee) or 1099 (subcontractor) from this employer at year end? W-2 1099 Have you filed a Workers’ Compensation claim? Yes No
Has the employer or the workers’ compensation carrier accepted or denied liability? accepted denied
Have you sought the assistance of an attorney relating to this accident/injury? Yes No If yes, please provide: Attorney’s name:
Attorney’s address: Attorney’s phone:
To the best of my knowledge the above information is true, accurate and complete. Unanswered questions indicate they do not apply. My signature authorizes any Medicare carrier, intermediary, insurance carrier, or plan to make available to my health insurance company, ____________________________________, all records necessary for processing claims filed by me or on my behalf. I authorize all insurance payments, including auto, and medpay to be made directly to Orthopedic Specialists of SW Florida.
of Patient Information Page
Reason for today's visit? If leg pain, what side
Describe where the pain is (what hurts, when it hurts): How did the injury occur?
Where did the injury occur? Date of injury
If no injury, when did the pain start?
What makes the problem worse? (please circle all that apply)
Heat, cold, exercise, movement, rest, sitting, standing, lying down, bending What makes the problems better? (please circle all that apply)
Heat, cold, exercise, movement, rest, sitting, standing, lying down, bending Is there anything else that helps the pain?
Is the pain worse in the AM or PM (circle)?
Does the pain keep you up at night yes or no (circle?) Are you having any bowel or bladder trouble?
Does the pain travel anywhere? (circle) arms, legs, feet, hands, buttocks, shoulder blade, trapezium
Is the pain different? How is it different?
Please circle all that apply to describe your pain:
Burning, throbbing, aching, sharp, dull, knife-like, pressure, pins and needles, stabbing, numbness, nagging stiffness, tightness, pulling, deep, superficial, falls asleep, constant, occasional
How bad is your pain from 0 to 10? (0 is no pain, 10 being the worst pain) Paint at its worst
Pain at its least
Have you seen any other physician for this problem? Doctor's name What treatment was given?
What medications were you given?
Did they take xrays? if so, of what? Where were the xrays taken? (office, hospital, imaging center)
Have you had any MRI/CT scans/physical therapy/Injections? of what
Where were they done? How long ago?