PATIENT REGISTRATION

WHITE ROCK ORTHOPEDIC ASSOCIATION

DATE

PATIENT INFORMATION

LAST NAME

FIRST NAME

M

DOB

AGE

SEX

NUMBER

STREET

CITY

STATE

ZIP

HOME PHONE

EMPLOYER

WORK ADDRESS

WORK PHONE

OCCUPATION

SS#

DRIVER LICENSE #

MARITAL STATUS

M S W D

REFERRED BY

PHYSICIAN RELATIVE FRIEND OTHER

PARTY RESPONSIBLE FOR PAYMENT AND/OR SPOUSE INFORMATION

NAME

DOB

AGE

SEX

ADDRESS

HOME PHONE

EMPLOYER

OCCUPATION

WORK PHONE

ADDRESS

SS#

IN CASE OF EMERGENCY

NEAREST RELATIVE OR FRIEND

NAME

ADDRESS

PHONE NO

INSURANCE INFORMATION

NAME OF INSURANCE CO. (PRIMARY)

NAME OF POLICY HOLDER (PRIMARY INS.)

ID #

GROUP #

MEDICARE #

MEDICAID #/EFF. DATE

NAME OF INSURANCE CO. (SECONDARY)

NAME OF POLICY HOLDER (SEC. INS.)

ID # (SECONDARY INSURANCE)

GROUP NO. (SEC. INS.)

IS THIS AN ON-THE-JOB INJURY?

SPORTS INJURY? AUTO ACCIDENT?

OTHER?

PATIENT REGISTRATION - PAGE TWO

WHITE ROCK ORTHOPEDIC ASSOCIATION

PATIENT INFORMATION

Referring Physician: Primary Care Physician:

CURRENT HISTORY

Reason for your visit: □ Illness □ Accident Date of onset for illness/injury:

PLEASE DESCRIBE YOUR CHIEF COMPLAINT:

GENERAL MEDICAL HISTORY

CHECK IF YOU HAVE HAD . . .

□ Diabetes □ High blood pressure □ Heart disease □ Heart attack □ Blood clots

□ Ulcer □ Asthma □ Emphysema □ Tuberculosis □ Gout

□ Kidney disease □ Arthritis □ Rheumatoid arthritis □ Stroke

□ Thyroid disease □ Cancer □ Hepatitis □ HIV

□ Other medical problems?

SURGERY:

□ Previous joint replacement? Which and when?

□ Back Surgery

□ Tonsillectomy □ Appendectomy □ Gall bladder □ Thyroid □ Hernia repair

□ Hemorrhoids □ Hysterectomy □ Heart surgery □ Cancer surgery

□ Other surgeries:

MEDICATIONS:

□ Coumadin □ Aspirin □ Prednisone □ Anti-inflammatory

Please list all other medications you are currently taking:

ALLERGIES TO MEDICATIONS: □ NO KNOWN DRUG ALLERGIES

□ Penicillin □ Sulfa □ Codeine

□ NSAIDS □ Iodine □ Aspirin □ Other:

SOCIAL HISTORY:

□ Do you smoke? How much?

□ Alcohol? How much? □ Social Drinker

□ Pregnant? How long?