Patient Registration New Patient Packet

Lone Star Orthopaedic Institute
Patient Registration

Patient Information

Patient’s Legal Name: Date of Birth:

Social Security Number:

Address: City, State, Zip:

Home Phone: Cell: Work:

Email Address:

I consent to receive the following (check all that apply): Voicemails Text Messages Emails

Gender: Female Male Other, not listed

Are you Hispanic or Latino? YES NO

Race: American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Black/African American
White Hispanic or Latino Choose not to disclose Other, not listed

Preferred Language: English Spanish Other

Pharmacy: Phone:

Address: City, State, Zip:

Primary Care Provider: Phone:

Referring Physician: Phone:

Responsible Party Information

Responsible Party: Self Guarantor

Responsible Party Name: Date of Birth:

Gender: Female Male Social Security Number: Phone:

Address: City, State, Zip:

Emergency Contact Information

Emergency Contact Name: Relationship:

Phone Number: Do you have a living will? Yes No

Consent for Treatment

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved.

This consent provides us with your permission to perform reasonable and necessary medical exams, testing and treatment. By signing below, you consent to treatment at this office or any other satellite office under common ownership.

Consent for Financial Communications

I acknowledge that as a courtesy, Lone Star Orthopaedic Institute may bill my insurance company for services provided to me. I agree to pay for services not covered, including co-payment, co-insurance, deductible, and any charges not covered by insurance.

A photocopy of this consent shall be considered as valid as the original.

Patient HIPAA Acknowledgement and Consent Form

I acknowledge that I have received the Notice of Privacy Practice and consent to the use of my information for treatment, payment, healthcare operations, and other permitted uses.

I authorize the following friends or family members to access my Protected Health information for communicating results, findings and care decisions.

Name: Relationship: Yes No

Name: Relationship: Yes No

Name: Relationship: Yes No

New Patient Intake

Date: Patient Name: DOB:

Preferred Language: Race/Ethnicity:

How were you referred to us?

Referring Physician Name:

Reason for Visit:

Are your symptoms related to an injury: Yes No Date of injury:

Aggravating Factors: Lifting Coughing Sneezing Standing Walking Sitting Climbing Stairs Other:

Describe your pain: Constant Intermittent Unchanged Worse Better
Burning Sharp-shooting Tingling Numbness Pinprick
Stabbing Deep-Pressure Tightness Spasms Other:

What makes pain worse?

What makes pain better?

How does the pain limit?

Is there any bowel or bladder problems?

How far are you able to walk without your symptoms causing you to stop and rest?

Do you use a: Walker Cane Wheelchair Motorized Scooter

Treatment & Eval: MRI X-Rays CT EMG Bone Scan Labs Epidurals

Treatment tried for pain: Physical Therapy How long? TENS Heating Pad Ice
Inversion Table Steroid Injection How many injections?
Surgery What kind? Chiropractor How long?
Exercise What kind? Medication Which?
Brace Which? Other

1. Have you noticed that you are dropping things or that your hands feel clumsy? Y N

2. Do you feel off-balance or unsteady on your feet? Y N

3. Do you feel weakness in one or both your arms or hands? Y N

4. Do you feel numbness or tingling in one or both of your arms or hands? Y N

Personal Health History

Name (First, Last): Today's Date:

DOB: Male Female Height: Weight:

Primary Care Provider/Clinic Name: Who referred you to this clinic?

Reason for todays visit:

When was your last flu vaccine? When was your last pneumonia vaccine?

Past Medical History:

Past Surgical History:

Other Hospitalizations:

Medications

Please include over the counter medications, vitamins, and supplements, or attach your medication list.

Name: Dose/Strength: Frequency: Prescribing Physician:

Name: Dose/Strength: Frequency: Prescribing Physician:

Name: Dose/Strength: Frequency: Prescribing Physician:

Have you ever had a problem/reaction with anesthesia? Yes No

If yes, please explain:

Are you allergic to any medications? Yes No

Allergy/Medication: Reaction:

Allergy/Medication: Reaction:

Social History

Marital Status: Single Partnered Married Separated Divorced Widowed

Children: Yes No If yes, how many? Ages?

Occupation: Retired Disabled Working Current Occupation

Health Habits

Do you drink alcohol? Yes No If yes, how many glasses a week? What type of alcohol?

Do you use tobacco? Yes Never No, quit Year

If yes, check all that apply: Cigarettes, per day Chew, per day
Pipe, per day Cigars, per day

Do you use illicit/recreational drugs? Yes No If yes, what kind?

Do you exercise? No Yes; 1-3 times/week Yes; 4 or more times/week Yes; active but no formal exercise

If yes, what type?

Personal Safety

Do you live alone? Yes No If no, who do you live with?

Do you use a cane? Yes No

Do you have frequent falls? Yes No Do you use a wheelchair? Yes No

Do you have an Advanced Directive or Living Will? Yes No

Modified Zung Depression Index

Patient Name