Patient Intake
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Gender
*
Male
Female
N/A
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Email
*
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employer
*
Occupation
*
Marital Status
*
Married
Separated
Divorced
Widowed
Single
Race
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Other
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Language
*
Emergency Contact/Next of Kin Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Is it okay to disclose your information to this person?
*
Yes
No
Other friends/family we may discuss treatment with?
*
Yes
No
Other friends and family..
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relationship
End
Mother's Maiden Name
*
Is Patient Under 18?
*
Yes
No
Is patient under 18?
Guardian Name
First Name
Last Name
Guardian Date of Birth
-
Month
-
Day
Year
Date
Guardian Phone Number
Please enter a valid phone number.
Guardian Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardian Social Security Number
End
Referral Information
Who referred you or how did you hear about us?
*
Referring Physician
*
Referring Physician Phone Number
*
Please enter a valid phone number.
Family Physician
*
Family Physician Phone Number
*
Please enter a valid phone number.
Lifestyle/Social History
Please describe your physical activity (list all sports, hobbies, etc)
*
Tabacco/Smoke
*
Current
Former
Never
Number of Years
Cigs/Day
Years Quit
Do you drink?
*
Yes
No
Frequency
Amount
Have you ever had a substance abuse problem? If yes, please explain
*
Patient Health Information
Height
*
Weight
*
Dominant Hand
*
Left
Right
Current Tetanus Shot?
*
Yes
No
Are you currently under the care of a physician?
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Yes
No
If yes, explain
Previous fractures, sprains, or surgeries?
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Yes
No
If yes, explain
Have you experienced or do you currently have any of the following?
General
Latex Allergy
Fever/Chills
Weight Loss
Musculoskeletal
Arthritis/Still or painful joints
Broken Bones
Muscle Disease
Ear/Nose/Throat
Frequent Respiratory Infections
Sinus Problems
Hay Fever
Respiratory
Tuberculosis (TB)
Difficulty Breathing
Asthma/Emphysema/COPD
Infectious
Hepatitis, or HIV+/AIDS
Neurologic
Fainting spells
Dizziness
Seizures
Frequent headaches
Cardiovascular
High Blood Pressure
Heart attack / murmurs
Heart valve problems
Low Blood Pressure
Congenital Heart Disease
Rheumatic/Scarlet Fever
Peripheral vascular disease
Stroke
Pacemaker
Endocrine
Hypothyroid / Hyperthyroid
Diabetes
Adrenal disease
Gastrointestinal
Colitis
Liver disease
Reflux/GERD
Hematology/Oncology
Anemia
Clotting disorder
Pulmonary embolism
Deep vein clots
Hemophilia or blood disorder
Cancer/Chemo/Radiation
Genitourinary
Frequent UTIs
Kidney disease
Psychiatric
Substance abuse
Psychiatric disorders
Depression / Anxiety
Please explain any of the above
Has anyone in your family experience the following?
Arthritis
*
Yes
No
Type?
Heart Disease
*
Yes
No
Type?
Muscle Disease
*
Yes
No
Type?
Diabetes
*
Yes
No
Type?
Cancer
*
Yes
No
Type?
Allergies
Allergies?
*
Yes
No
If yes, explain what, severity, reaction, onset, and any additional comments
Current medications
*
Yes
No
If yes, please list medication, start date, strength, dosage, and diagnosis
** PRIVATE INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS AND INFORMATION RELEASE
I, the undersigned, authorize payment of medical benefits to Gunnison Valley Orthopedics for any services furnished to me by the physician(s). I understand that I am financially responsible for any amount not covered by my contract. I also authorize you to release to my insurance company information concerning health care, advice, treatment, or supplies provided to me. This information will be used for the purpose of evaluation and administering claims of benefits.
*
** MEDICARE LIFETIME SIGNATURE ON FILE
I request that payment of authorized Medicare benefits be made either to me or on behalf of Gunnison Valley Orthopedics for any services furnished to me by the physicians. I authorize any holder of medical information about me to be released to the healthcare financing administration and its agents any information needed to determine these benefits or benefits payable for related services.
*
Signature
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and will only be shared with those authorized by me on page 1 of this document. I understand it is my responsibility to inform this office of any change in my medical status.I hereby authorize the Doctor/Physician and/or Assistant/Nurse to provide medically necessary services, including x-rays, fracture treatment, casting, or other procedures deemed to be in the best interest of the patient. By signing below, I hereby acknowledge that I have been provided with a copy of this office's Notice of PrivacyPractices and have therefore been advised of how my protected health information may be used and disclosed by the office. In addition, by signing below, I hereby consent to the use and disclosure of my healthcare information for treatment purposes, payment activities and healthcare operations of the office.
Signature of Patient or person legally authorized to sign
*
*** PRESCRIPTION REFILL POLICY ***
For our NON-SURGICAL patients: If warranted and prescribed, we will provide ONE Rx for seven (7) days with NO ADDITIONAL REFILLS. If you require an additional prescription, you must see your primary care physician. For our SURGICAL patients: As dictated by Senate Bill 18-022 prescription pain killers shall only be administered for seven (7) days unless otherwise prescribed further by your physician; beyond 14 days you must see your primary care physician.
I have read and understand the Prescription/Refill Policy as stated above.
*
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