Today’s Date:__________________________________________________ Name: ________________________________________________________ Mailing Address:________________________________________________ City, State, Zip: _________________________________________________ In case of Emergency, Notify: _____________________________________ Phone: ________________________________________________________ Relationship to patient: ___________________________________________ Sex: Male ( ) Female ( ) Referred by: ____________________________________________________ Phone: ________________________________________________________ Insurance Information Primary Insurance: _______________________________________________ Mailing Address: ________________________________________________ City, State, Zip: _________________________________________________ Name/Policy Holder: _____________________________________________ SSN: __________________________________________________________ Secondary Insurance: _____________________________________________ Mailing Address: ________________________________________________ City, State, Zip: _________________________________________________ Name/Policy Holder: _____________________________________________ SSN: __________________________________________________________ Employment Information Employer: _____________________________________________________ Mailing Address: _______________________________________________ Telephone: ____________________________________________________ City, State, Zip: _________________________________________________ Responsible Party Information Name: ________________________________________________________ Mailing Address: ________________________________________________ City, State, Zip: _________________________________________________ SSN: __________________________________________________________ Account #_____________________ Marital Status: Married ( ) Single ( ) Widowed ( ) Divorced ( ) Home Phone: ________________________ Cell Phone: _________________ Age: _________ E-Mail: ________________________________________ DOB: _____________ Preferred Language: _______________________ ID Number: ________________________ Group Number: _______________ ID Number: ________________________ Group Number: _______________ DOB: __________ Relationship to Patient: __________________________ DOB: __________ Relationship to Patient: __________________________ DOB: __________ E-Mail: _______________________________________ Payment of Benefits I authorize payment of benefits, as determined by the insurance company, directly to the physician’s office. I understand that I still may be responsible for any amounts not paid by my insurance company. Signature: ____________________________________________________________________ Date: ___________________________________ Medical Release Authorization I authorize any insurance company, organization, employer, hospital, physician, dentist, or pharmacist to release any information requested with regard to processing my claim. I certify that all information on this form is true and correct to the best of my knowledge. I know it is a crime to fill out this form with facts I know are false or to leave out facts I know are important. Signature: ____________________________________________________________________ Date: ___________________________________ Cancellation of Scheduled Appointments I understand that if I have a serious emergency and I am unable to come to my appointment, I will contact the office as soon as possible. In other cases, if I fail to cancel my appointment 24 business hours in advance, I will be charged $50.00 for the missed appointment. Signature: _____________________________________________________________________ Date: __________________________________ As the responsible party, I agree that all charges that are not directly paid by the insurance company will be my responsibility X ____________________________________________________________ Responsible Party Signature Phone: ________________________________________________________ New Patient Registration Form Rheumatology - Dr. Mary Olsen, MD SSN: _____________________ Preferred Pharmacy: ____________________
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Payment of Benefits I authorize payment of benefits, as determined by the insurance company, directly to the physician’s office. I understand that I still may be responsible for any amounts not paid by my insurance company. Signature: ____________________________________________________________________ Date: ___________________________________ Medical Release Authorization I authorize any insurance company, organization, employer, hospital, physician, dentist, or pharmacist to release any information requested with regard to processing my claim. I certify that all information on this form is true and correct to the best of my knowledge. I know it is a crime to fill out this form with facts I know are false or to leave out facts I know are important. Signature: ____________________________________________________________________ Date: ___________________________________ Cancellation of Scheduled Appointments I understand that if I have a serious emergency and I am unable to come to my appointment, I will contact the office as soon as possible. In other cases, if I fail to cancel my appointment 24 business hours in advance, I will be charged $50.00 for the missed appointment. Signature: _____________________________________________________________________ Date: __________________________________
As the responsible party, I agree that all charges that are not directly paid by the insurance company will be my responsibility X ____________________________________________________________ Responsible Party Signature Phone: ________________________________________________________
New Patient Registration Form Rheumatology - Dr. Mary Olsen, MD
Date symptoms began (approximate): ______________________________________________________ Diagnosis: _____________________________________________________________________________________________________
Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later):
Name/RelationshipArthritis (unknown type) Lupus or “SLE”
Osteoarthritis Rheumatoid Arthritis
Gout Ankylosing Spondylitis
Childhood Arthritis Osteoporosis
Other arthritis conditions: ________________________________________________________________________________________________________________________________________________________________________________________________________________
Please shade all the locations of your pain over the past week on the body figures and hands.Example:
LEFT RIGHT LEFT
LEFT RIGHT
Adapted from CLINHAQ, Wolfe F and Pincus T. Current Comment – Listening to the patient – A practical guide to self report questionnaires in clinical care. Arthritis Rheum. 1999;42 (9): 1797-808. Used by permission.
Referred here by: (check one) Self Family Friend Doctor Other Health Professional
Name of person making referral: __________________________________________________________________________________________________________________________________________________________________________________________________
The name of the physician providing your primary medical care:___________________________________________________________________________________________________________________________________________
Describe briefly your present symptoms: ___________________________________________________________________________________________________________________________________________________________________________________
q Recent weight loss amount _________________________________________________________
q Fatigueq Weaknessq Feverq Eyesq Painq Rednessq Loss of visionq Double or blurred visionq Drynessq Feels like something in eyeq Itching eyes
Ears-Nose-Mouth-Throatq Ringing in earsq Loss of hearingq Nosebleedsq Loss of smellq Dryness in noseq Runny noseq Sore tongueq Bleeding gumsq Sores in mouthq Loss of tasteq Dryness of mouthq Frequent sore throatsq Hoarsenessq Difficulty swallowing
Cardiovascularq Chest Painq Irregular heart beatq Sudden changes in heart beatq High blood pressureq Heart murmurs
Respiratoryq Shortness of breathq Difficulty breathing at nightq Swollen legs or feetq Coughq Coughing of bloodq Wheezing (asthma)
Gastrointestinalq Nauseaq Vomiting of blood or coffee ground
materialq Stomach pain relieved by food or milkq Jaundiceq Increasing constipationq Persistent diarrheaq Blood in stoolsq Black stoolsq Heartburn
Genitourinaryq Difficult urinationq Pain or burning on urinationq Blood in urineq Cloudy, “smoky” urineq Pus in urineq Discharge from penis/vaginaq Getting up at night to pass urineq Vaginal drynessq Rash/ulcersq Sexual difficultiesq Prostate trouble
For Women Only:Age when periods began: _____________________________
Periods regular? q Yes q NoHow many days apart? __________________________________
Date of last period? / /Date of last pap? / /Bleeding after menopause? q Yes q NoNumber of pregnancies? _______________________________
Number of miscarriages? ______________________________
Musculoskeletalq Morning stiffness
Lasting how long? ______________________Minutes ______________________Hours
Integumentary (skin and/or breast)q Easy bruisingq Rednessq Rashq Hivesq Sun sensitive (sun allergy)q Tightnessq Nodules/bumpsq Hair lossq Color changes of hands or feet in
the cold
Neurological Systemq Headachesq Dizzinessq Faintingq Muscle spasmq Loss of consciousnessq Sensitivity or pain of hands and/or feetq Memory lossq Night sweats
Cups/glasses per day? ___________________________________________________________________________
Do you smoke? q Yes q No q Past – How long ago? __________________
Do you drink alcohol? q Yes q No Number per week _________________
Has anyone ever told you to cut down on your drinking?
q Yes q No
Do you use drugs for reasons that are not medical? q Yes q NoIf yes, please list: _______________________________________________________________________________
Any previous fractures? q No q Yes Describe: ___________________________________________________________________________________________________________________________________________________________________
Any other serious injuries? q No q Yes Describe: _____________________________________________________________________________________________________________________________________________________________
FAMILY HISTORY
IF LIVING IF DECEASED
Age Health Age at Death Cause
Father
Mother
Number of siblings _______________________ Number living ________________________ Number decreased ______________________
Number of siblings _______________________ Number living ________________________ Number decreased ______________________ List ages of each____________________________________________________
Health of children _______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you know any blood relative who has or had: (check and give relationship)
Type of reaction: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________
PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.)Name of Drug Dose (include
strength & number of pills per day)
How long have you taken this
medication
Please check: Helped?
A Lot Some Not At All
1. q q q
2. q q q
3. q q q
4. q q q
5. q q q
6. q q q
7. q q q
8. q q q
9. q q q
10. q q q
PAST MEDICATIONS: Please review this list of “arthritis” medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided.
Do you have stairs to climb? q Yes q No If yes, how many?
How many people in household? ____________________________________Relationship and age of each ________________________________________________________________________________________________________
Who does most of the housework? _________________________ Who does most of the shopping? _______________________ Who does most of the yard work? ____________________
On the scale below, circle a number which best describes your situation; Most of the time, I function…
1 2 3 4 5
VERY POORLY OK WELL VERYPOORLY WELL
Because of health problems, do you have difficulty: (Please check the appropriate response for each question.) Usually Sometimes NoUsing your hands to grasp small objects? (buttons, toothbrush, pencil, etc.) ............................................................. q q q
Getting up from chair? ................................................................................................................................................. q q q
Touching your feet while seated? ................................................................................................................................. q q q
Reaching behind your back? ....................................................................................................................................... q q q
Reaching behind your head? ....................................................................................................................................... q q q
Going to sleep? ............................................................................................................................................................ q q q
Staying asleep due to pain? ......................................................................................................................................... q q q
Getting along with family members? ............................................................................................................................ q q q
In your sexual relationship?.......................................................................................................................................... q q q
Engaging in leisure time activities? .............................................................................................................................. q q q
With morning stiffness ................................................................................................................................................. q q q
Do you use a cane, crutches, walker or wheelchair? (circle one) ............................................................................... q q q
What is the harde st thing for you to do?__________________________________________________________________________________________________________________________________________________________________________________
Are you receiving disability? ...................................................................................................................................Yes q No q
Are you applying for disability? ...............................................................................................................................Yes q No q
Do you have a medically related lawsuit pending? .................................................................................................Yes q No q