New Patient Medical History Questionnaire

NEW PATIENT MEDICAL HISTORY QUESTIONNAIRE

DATE: DOCTOR:
NAME: AGE:
SOCIAL SECURITY #:
HEIGHT: WEIGHT: SEX: MALE FEMALE
DATE OF BIRTH: RACE:
E-MAIL ADDRESS (IF AVAILABLE):
If healthcare information was made available on the internet, would you access it? Yes No

Emergency Contact (Someone NOT in your home):
Name: Phone:

How did you learn about our physicians?

Physician referral Community/Physician Seminar Friend/Relative Community Newsletter
Internet
Other:

Good Samaritan Hospital Manual Outpatient Medicare Questionnaire

Medicare requires that the following questions be asked and answered for each date of any inpatient or outpatient service rendered. Failure to answer these questions and provide accurate information may result in a denial by Medicare to pay for any claim. Read each question carefully and answer by checking a yes or no in the appropriate box.

Both patient and spouse retirement dates are required. Disability dates for those recipients under the age of 65 and other possible insurance carriers. Renal patients please provide the start date for dialysis and answer the information in question 11.

Worker's Compensation claims with Medicare as your Medicare carrier answer question 6 below and all Medicare questions. If an automobile accident provide date of accident and auto insurance carriers name and address and answer question 8 and all Medicare questions.

Managed Care Health Maintenance Organizations require preauthorization and referrals in most cases. This is your responsibility to obtain prior to having services rendered. Our staff will coordinate the verification and authorization with your physician. A managed care form signed is necessary for all managed care carriers.

Patient's Signature:

Is the patient a member of a Health Maintenance Organization (HMO), or a Medical Health Maintenance Organiziation, exluding a Medicare Supplemental? Yes or No

If Yes, the name of your insurance, address, telephone number, member or policy number, social security number of member and the name and phone number of your primary physician.

Name of HMO: Phone:
Address:
Policy Number: Member:
Social Security Number:
Primary Care Physician:

Is the patient a member of a hospice organization and is the illness related to the patient's terminal illness?
Yes No
Are you receiving black lung? Yes or No Date Benefits Began:
Is illness covered by black lung? Yes No
Are the services to be paid by a government program such as a research grant? Yes No
Has the Department of Veteran's Affairs authorized and agreed to pay for services at this facility? Yes No
Is the injury due to a worker-related accident/condition? Yes No
Date of Injury: Insurance Company:
Employer (where injury occurred):
Address and Telephone Number for Insurance:

Claim # and your social security number:
Is injury due to non work-related injury? Yes No
Date of Accident:
Was the illness/injury caused by an automobile accident? Yes No
Was another party responsible for this accident? Yes No
Are you entitled to Medicare based on age: Yes No
Retirement Date for Patient:
Retirement Date for Spouse:
Disability-Start Date:
Is disability entitled to any member of your family employed? Yes No
If yes, where?:
End Stage Renal: Start Date:

Please Check Applicable Response

Knee	Hip	Ankle	Foot	Leg	Shoulder	Hand	Wrist
R L	R L	R L	R L	R L	R L	R L	R L

Other

LOCATION OF PAIN:
Knee All Over Inside Front Outside Along prior scar Back
Hip Groin Buttocks Inside of Thigh Front of Thigh Outside of Thigh
Ankle All Over Outside Inside Top Bottom
Foot All Over Outside Inside Top Bottom
Leg All Over Outside Inside Thigh Calf
Shoulder Outside Inside Front Back
Hand All Over Fingers Palm Back
Wrist All Over Outside Inside Top

SYMPTOMS: First began:
Days Ago Weeks Ago

Started because of:
Twisting Injury Fall/Sports Injury Fracture/Break Motor Vehicle Accident Contusion
Spontanously Other (describe):

Increased In:

Frequency

Intensity

Both

Days Ago Weeks Ago Months Ago Years Ago

PAIN: (check both intensity and duration)

On Weight-Bearing: None Slight Mild Moderate Severe Totally Disabling
Rarely Intermittently Continous

Rest Pain: None Slight Mild Moderate Severe Totally Disabling
Rarely Intermittently Continous

Night Pain: None Slight Mild Moderate Severe
Rarely Intermittently Continous

SYMPTOMS WORSENED BY:

Walking Standing Sitting Stairs Lifting Carrying

SYMPTOMS IMPROVED BY:

Nothing Walking Rest Heat Ice
Medications taken for symptoms? Yes No

LIMP: None Mild Moderate Moderate-Severe Severe

SUPPORT NEEDED: None 1 Crutch 2 Crutches Cane (long walks)
Cane Full Time 2 Canes Walker Unable to walk

PLEASE CHECK APPLICABLE RESPONSE

WALKING DISTANCE

With Support	Without Support
Unlimited	Unlimited
More than 1 Mile	More than 1 Mile
1/2 to 1 Mile	1/2 to 1 Mile
1/4 to 1/2 Mile	1/4 to 1/2 Mile
1 Block	1 Block
Less than 1 Block	Less than 1 Block
Indoors Only	Indoors Only
Unable	Unable

STAIR CLIMBING: Normal Holding on with 1 hand Holding on with 2 hands
One step at a time Unable to climb stairs

PHYSICAL ACTIVITY LEVEL: Heavy Labor Active Moderately Active
Sedentary Moderately Restricted Marked Restricted

BRACE: No Yes Type:

PHYSICAL THERAPY ATTENDED:

Yes

HELPFUL

NOT HELPFUL

TESTS YOU HAVE HAD DONE: (please check all that have been done for this problem)

X-rays	Nerve Tests	CT Scan	Bone Scan	Blood Tests
MRI	Arthrogram	Fluid Analysis	Diagnostic Arthroscopy	EMB
Sonogram	Mylogram	Joint Fluid Withdrawals	Injections
Other:

STEROID USE
Have you taken steroids during the last month? Yes No
If so, current does (mg/day)
Date of last dose
Have you taken steroids at any time during your lifetime? Yes No

If yes, please complete the following table.
Please use the following categories for duration: <1month; 1-2 months; 2-3 months; 3-6 months; or >6 months

MEDICATION	DOSE (mg/day)	DURATION

Common Steroids
Cortisone	Sterapred packs
Prednisone	Cortisone acetate
Prednisolorie	Decadron
Dexanethasone	Hydrocortone
Corticosteroids	Solumedrol
Prelone syrup	Celestone

Please answer the following questions.

If you do not know the answer, write in D.K. for don't know.
What is the highest dose of steroids you have ever taken?
How long did you take this dose?

Why were you prescribed steroids?

Nephrotic Syndrome	Kidney Transplantation	Other Kidney Disorder
Other Organ Transplantations	Skin Disorder	Collagen Disease
Herb Medication	Brain or Spine Surgery	Blood Disorder
Rheumatoid Arthritis	Systemic Lupus Erythematosus	Allergy
Asthma	Other

MEDICATIONS:
General Medications (FOR JOINT PROBLEMS) Please number as applies

1 - Taking now, helps	2 - Taking now, not helping	3 - Took - no help
4 - Took, helped	5 - Took, unable to tolerate

Aspirin		Feldene
Plaquenil		Indocin
Clinoril		Trilisate
Gold		Steroids
Butazalidin		Nalfon
Tolectin		Motrin
Prednisone		Volteran
Meclomen		Ansaid
Vioxx		Celebrex
Other

Pain Medications (FOR JOINT PROBLEMS) Please number as applied

1 - Taking now, helps	2 - Taking now, not helping	3 - Took - no help
4 - Took, helped	5 - Took, unable to tolerate

Aspirin		Tylox (Percocet)
Darvon		Dilaudid
Percodan		Morphine
Tylenol		Talwin
Codiene		Demerol
Tylenol #3		Tylenol #4
Vicodan		Lortab mg
Ultram
Other

Please list all medications you are currently taking on a routine basis. This would include blood thinners, insulin, aspirin, thyroid medicine, etc.

VITAMINS/SUPPLEMENTS:
Please list all vitamins, minerals and supplements you take on a routine basis.

ACTIVITIES:
(Please indicate applicable response)

1 = Currently able to do

2 = Cannot currently do, but would like to be able to do

Carrying	Lifting	Stooping	Stairs
Skiing	Golf	Tennis
Other:

MAJOR JOINT SURGERY

Joint	Procedure	Helpful	Complications during or after surgery

BLOOD CLOTS:
Have you ever had blood clots (thrombophlebitis) in your leg veins? Yes No When?
Were you hospitalized? No Yes How Long?

How was diagnosis made? Doctor's Suspicion Dye x-ray into veins Scan
Ultrasound Doppler Other:
Treatment Given: Heparin Coumadin No Treatment Other

Joint Injections: No Yes HELPFUL NOT HELPFUL

If Yes, how many and how long have you been receiving them
Approximately how long since your last injection

OTHER ORTHOPEDISTS SEEN:

Physician's Name	Approximately how long ago did you last see them	Was surgery recommended	Type of surgery recommended

MEDICAL CONDITION
GENERAL HEALTH: Excellent Good Fair Poor
HEAD Headaches History of Accidents
NECK Stiffness Pain Arthritis Thyroid Problem
SKIN Infections Boils Psoriasis
EYES

Glasses	Cataract	Cataract Surgery	Pain	Legally Blind
Yes No	Right Left	Right Left	Right Left	Right Left

EARS

Hearing Loss	Hearing Aid	Ringing/Buzzing	Infection
Right Left	Right Left	Right Left	Right Left

NOSE/THROAT Bleeding Hoarseness Polyps Sinus Problems Trouble Swallowing
RESPIRATORY Asthma Wheezing Chronic Cough Shortness of Breath
Coughing up Blood Pain on Breathing

PLEASE CHECK ANY/ALL PROBLEMS ON THE FOLLOWING:

HEART	STOMACH/BOWEL
Chest Pain	Ulcer
Heart Disease	Loss of Appetite
Leg Cramps - Night	Swelling
Leg Cramps - Walking	Constipation
Leg/Ankle Swelling	Hemorrhoids
Irregular Heartbeat	Colitis
Fast Heartbeat	Nausea/Vomiting
High Blood Pressure	Pain
Low Blood Pressure	Change in Bowel Habits
Cold Fingers/Toes	Gall Bladder Problems
Sweating Fingers/Toes	Pancreatittis
Other	Other

BLEEDING	METABOLIC
Anemia	Diabetes
	Hypoglycemia
Other	Other

URINARY
Leakage	Strong Urine
Pain on Urination	Back Pain
Sores on Genitalia	Discharge/Drainage
Bloody Urine	Frequent Urination
Trouble Starting Urination	Night Time Urination
Trouble Stopping Urination	Infections
Herpes	AIDS
	AIDS Related Complex

NEUROLOGICAL	PSYCHOLOGICAL
Headaches	Nervous Breakdown
Seizures (Epilepsy)	Crying Frequently
Paralysis	Tension
Fainting	Feeling Blue
Stroke (R L)	Anxious
Numbness	Stress Prone
Other	Cannot Sleep
	Exhaustion
	Other

PRIOR SURGERIES
Neck Fusion	Gall Bladder Removal
Back Fusion	Caesarian Section
Brain Surgery	Appendectomy
Thyroid Surgery	Prostate Removal
Heart Bypass	Balloon Angioplasty
Bowel Removal	Bladder Repair
Kidney Removal	Hemorrhoidectomy
Hysterectomy	Tubal Ligation
Kidney Stones	Vascular Surgery
Lumbar Disc Removal	Vein Ligation/Stripping
Cataract Removal	Hernia Repair R L
Chest Surgery	Stomach Removal
Colostomy	Other:

HOSPITALIZATIONS
Please list any major hospitalizations and the age at which they occurred:

PRIOR DISEASE		ALLERGIES (list specifics)
Hepatitis	Systemic Infection	Pollen
Syphilis	Local Infection	Medicines
AIDS	Joint Infection	Foods
Herpes		Other

CANCER
Type:
Primary Site:
Metastasis (spread) to:

FEMALE HISTORY

Menopause	Number of Pregnancies
Regular Menstration	Number of Live Births
Irregular Menstration	Birth Control Pills Currently In Past IUD

ALCOHOL HISTORY