PATIENT INTAKE FORM

None

JEFFERSON ORTHOPEDIC CLINIC

Mark Juneau, Jr., M.D.
Matthew R. Grimm, M.D.

Wesley A. Clark, M.D.
Barton L. Wax, M.D.

Scott A. Tucker, M.D.
John M. Kesler, PA-C

PREFERRED PROVIDER

Dr.Juneau

Dr.Grimm

Dr.Clark

Dr.Wax

Dr.Tucker

John Kesler, PA-C

PREFERRED PHARMACY

Pharmacy Name:

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Pharmacy Phone #:

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Pharmacy Fax #:

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Pharmacy Address:

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PATIENT

Patient First Name

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Patient Last Name

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Middle Initial:

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Preferred Name:

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Maiden Name:

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Date of Birth:

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SSN#:

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Sex:

Other

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Drivers License #:

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State:

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Primary Language:

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Religion:

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Ethnicity:

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Home Address:

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City:

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State:

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Zip:

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Country:

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Parish:

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Home Phone #:

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Cell #:

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Primary Work #:

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Primary Work Contact #:

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Fax:

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Preferred Communication:

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Are you employed?

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Are you a student?

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Reason for visit:

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If an accident, date of accident:

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Place of accident:

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Did you go to the hospital?

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If yes, what hospital did you go to?

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EMPLOYER (or Parents Employer)

Name of Company:

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Work Phone:

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Occupation:

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Address:

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City:

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State:

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Zip:

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Emergency Contact (Friend or Relative not living with you)

Name of Contact

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Phone / Cell / Pager #:

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Your relationship to emergency contact:

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SPOUSE INFORMATION

Spouse's Name:

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Phone / Pager #:

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Employer:

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Work Phone:

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INSURANCE INFORMATION

Give insurance card and Driver's License to receptionist upon arrival

Insured Name:

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Primary Insurance:

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Policy or ID #:

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Group Name:

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Group Number:

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Mailing Address:

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City:

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State:

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Zip:

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SECONADARY INSURANCE INFORMATION

Give insurance card and Driver's License to receptionist upon arrival

Insured Name:

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Secondary Insurance:

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Policy or ID #:

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Group Name:

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Group #:

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Mailing Address:

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City:

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State:

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Zip:

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CONSENT FOR TREATMENT

I as a patient consent to medical care including examination, diagnostic, or surgical treatment by the treating physician and such associates or assistants as may be deemed necessary. I am aware that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of any treatment.

Patient Signature:

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Date:

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AUTHORIZED RELEASE OF INFORMATION

I hereby authorize Jefferson Orthopedic Clinic to release those medical records pertaining to my treatment to any entity that is responsible for payment of physician charges. I understand that this authorizes my insurance company to pay any benefits directly to Jefferson Orthopedic Clinic. In addition, I further understand that I am ultimately responsible for charges incurred for services rendered, and that collection fees will be added to balance not paid in a timely manner.

Patient Signature:

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Date:

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Referring Physician:

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Referring Physician Phone:

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Referring Physician Address:

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CHIEF COMPLAINT - Why are you seeing the doctor today?

Injured Body Part (Check all that apply)

Shoulder

Neck

Back

Arm

Hand

Elbow

Hip

Knee

Ankle

Leg

Foot

Other:

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Date of Incident:

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Your Current Medical Problem is the result of:

Car Accident

Work Accident

Accident

Sport Injury

Other

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This occurred during:

Lifting

Pulling

Running

Twisting

Falling

Bending

Squatting

Reaching

Hit by Object

Other:

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HISTORY OF PRESENT ILLNESS:

Rate your pain or discomfort using this scale: None = 0, Severe = 10

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How long does your pain or discomfort last?

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For what period of time has this problem existed?

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Describe it. Check all that apply.

Sharp

Dull

Burning

Throbbing

Electric Shock

Tingling

Numbness

Swelling

Locking

Popping

Catching

Stiffness

Giving Way

When does your pain and discomfort occur? Check all that apply:

Walking

Standing

Rising From Chair

During Exercise

After Exercise

Running

Going Up Stairs

Going Down Stairs

At Work

After Work

At Night

When Asleep

Other:

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What makes your pain or discomfort better? Check all that apply

Rest

Therapy

Medication

Heat

Cold

Exercise

Brace

Bandage

Other:

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Have you had any other treatment for this problem?

Yes

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If YES, explain by who, when & where:

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Have you had any X-rays, MRIs, CT Scans, Bone Scans, Blood or Lab work in the past for this problem?

Yes

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If yes, check all previous testing done:

X-Rays

MRIs

CT Scans

Bone Scans

Blood or Lab Work

Medications

Medication Allergies - Please list:

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Current Medications (If you don't know how to spell the medication, please inform the nurse when seen)

Please list the medication dose and how long you've been taking them:

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Are you currently or have you had problems with your:

Cardiovascular (Blood Pressure, Chest Pain)

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If yes, please explain:

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Arthritis (Rheumatoid, Osteosarthritis):

Please select an option.

If yes, please explain:

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Neurologic (Numbness, Tingling, Balance):

Please select an option.

If yes, please explain:

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Constitutional (Weight Loss, Diet, Development):

Please select an option.

If yes, please explain:

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Stomach Ulcers:

Please select an option.

If yes, please explain:

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Diabetes:

Please select an option.

If yes, please explain:

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Liver Disease:

Please select an option.

If yes, please explain:

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Blood Clots:

Please select an option.

If yes, please explain:

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Disabled:

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If yes, please explain how and when:

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PAST MEDICAL HISTORY

Please indicate any major surgeries / hospitalizations / major injuries, the year they occurred and if there were any complications:

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Have you ever had general anesthesia (put to sleep)?

Yes

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If yes, were there any problems?

Yes

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If yes, please explain the problem:

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FAMILY MEDICAL HISTORY

Please complete to the best of your knowledge.

Mother

Alive or Deceased?

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Health Status

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If deceased, cause of death:

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Father:

Alive or Deceased?

Please select an option.

Health Status

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If deceased, cause of death:

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Sister/Brother:

Alive or Deceased?

Please select an option.

Health Status:

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If deceased, cause of death:

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Children

Alive or Deceased?

Please select an option.

Health Status:

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If deceased, cause of death:

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SOCIAL HISTORY

Are you employed?

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If yes, occupation:

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Marital Status

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Do you have children?

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Do you live with:

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Do you exercise?

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If yes, what type or kind?

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Are you on any kind of special diet?

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If yes, what type or kind?

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Have you had a history of substance abuse?

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If yes, please explain:

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Do you smoke?

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If yes, how long have you smoked?

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How many packs per day?

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Do you drink alcohol?

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If yes, how much?

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How long?

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Education

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ACKNOWLEDGEMENT OF OUR NOTICE OF PRIVACY PRACTICES

I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Jefferson Orthopedic Clinic\'s Notice of Privacy Practices. By signing below I am "only" giving acknowledgement that I have received or have had the opportunity to receive the Notice of our Privacy Practices.

Date

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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.

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