Worker's Comp and Motor Vehicle Accident Form
Central Jersey Hand Surgery
Name
*
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
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Day
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1920
Year
Age
Gender
*
Please Select
Male
Female
Gender neutral
Transgender
Non-Binary
Cisgender
Other
Cell Phone Number:
*
Home Phone Number
Please enter a valid phone number.
E-mail
*
example@example.com
Social Security Number
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
*
Please Select
Single
Married
Divorced
Partnered
Widowed
Legally separated
Employment / Student Status
*
Full time
Part time
Not Employed
Self Employed
Retired
Military Duty
Name of Employer
Work Phone Number
Please enter a valid phone number.
Do NOT call me at work
Employee Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation / Former Occupation
How did you hear about CJHS or who referred you?
Referring MD
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Family Physician
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Race
*
Please Select
Asian
Black / African American
American Indian
White
Multiracial
Do not want to report
Ethnicity
*
Please Select
Hispanic / Latino
Not Hispanic / Latino
Do not want to report
Covering Insurance
Insurance Company
*
Claim Number
*
Insurance Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Adjuster's Name
*
First Name
Last Name
Adjuster's Phone Number
*
Please enter a valid phone number.
Primary Insurance
Insurance Company
*
Specialist Copay
Effective Date
*
-
Month
-
Day
Year
Date
ID #
*
Group #
*
Insured Name
First Name
Last Name
Address, if different
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Insured
Insured Birthdate
-
Month
-
Day
Year
Date
Insured Social Security #
Injury / Accident Information
Date of Injury / Accident
*
-
Month
-
Day
Year
Date
Where did the Injury / Accident occur?
*
How did the Injury / Accident occur?
*
Description of problem(s) and symptoms
*
Pain Level (0-10) 10 is the worst
*
Previous treatments and surgeries for injury
Guardian / Spouse's Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
In case of emergency (if different than above)
Emergency Contact:
*
First Name
Last Name
Relationship
*
Contact Number
*
Patient Medical History Questionnaire
Weight (pounds)
*
Height (inches)
*
Ever have a flu vaccine
*
Yes
No
Date
-
Month
-
Day
Year
Date
Ever have pneumonia vaccine
*
Yes
No
Date
-
Month
-
Day
Year
Date
Have you had the Covid-19 vaccine
*
Yes
No
Date of first dose
-
Month
-
Day
Year
Date
Date of second dose (if given)
-
Month
-
Day
Year
Date
Vaccine Brand
Pfizer
Moderna
Johnson and Johnson
Hand Dominance
*
Right handed
Left handed
Ambidexturous
Past Medical History
Diabetes
Heart Disease
Heart Attack
High Blood Pressure
High Cholesterol
Thyroid Disease
Congestive Heart Failure
Thyroid Disease
Lyme Disease
Multiple Sclerosis
Asthma
Emphysema / COPD
Stomach Ulcer
Bleeding Disorder
Enlarged prostate
Rheumatoid Arthritis
Seizure Disorder
Vascular Disease
Glaucoma
Aneurysm
Gout
Anemia
Kidney Disease
Sleep Apnea
Gastric Reflux
Depression
Hepatitis
HIV Positive
COVID 19
Cancer
NONE
Any other medical conditions Please describe: Type of cancer Hepatitis type if positive
Past Surgical History
Knee Arthroscopy
Shoulder Arthroscopy
Joint replacement
Spine surgery
Eye surgery
Coronary artery bypass
Stents
Laparotomy
Hernia repair
Peripheral Bypass surgery
Cardiac catheterization
Hysterectomy
Carpal tunnel relase
Trigger finger release
DeQuervain decompression
Thumb basal joint arthroplasty
Other surgeries not listed above
Taking any medications, currently?
*
Yes
No
If yes, please list it here with dosage and frequency
Do you have any allergies?
*
Yes
No
Allergies and type of reaction
Do you presently smoke?
*
Yes
No
Former smoker
How much did you smoke?
Light
Heavy
Social
Alcohol Use per Week
*
None
1-6
7-14
15 or greater
Do you use illicit drugs?
*
Yes
No
What kind?
Education level
*
Please Select
Some High School
High School
Some college
College
Graduate / Higher
Other
Sports Participation
Review of Systems
Musculoskeletal
Numbness / Tingling
Weakness
Locking / Clicking
Pain
Constitutional
Fever
Night sweats
Weight loss
Eye
Red eyes
Dry eyes
Blurring vision
Vision loss
Ears / Nose / Throat
Nose bleeds
Sore throat
Hearing loss
Cardiovascular
Chest pain
Palpitations
Leg swelling
Respiratory
Shortness of breath
Cough
Wheezing
Gastrointestinal
Nause
Vomiting
Diarrhea
Genitourinary
Burning with urination
Blood in urine
Urinary incontinence
Skin
Rash
Hives
Skin infection
Neurological
Headache
Tremor
Seizures
Psychiatric
Depression
Anxiety / Panic attacks
Suicidal ideation
Endocrine
Excessive thirst
Cold intolerance
Excessive sweating
Hematological / Lymphatic
Easy bruising
Swollen glands
Easy bleeding
Allergy / Immune
Runny nose
Sinus congestion
Itchy eyes
Describe symptoms and the treatments received for conditions above
Any other info you would like the doctor to know?
I hereby authorize payment from the insurance company to be sent directly to Central Jersey Hand Surgery for any service rendered to me by the group. I also authorize the release of medical information to my insurance company in order for Central Jersey Hand Surgery to complete necessary insurance forms. You are personally responsible for the payment of all bills, if your claim is denied (for any reason). You are also responsible for any co-insurance amounts, non-covered charges and any balance remaining after insurance payment to our office. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees will be given to me concerning the results of any treatment or operation. Doctors Pess, Decker, Gabuzda, Atik, Fedorcik and Ruskin will attempt to improve the patient, but cannot return the patient to normal status.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Reviewed by Doctor: ____________________________________
Date reviewed by Doctor: ________________________________
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