Physician address. Physician phone

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1 PATIENT QUESTIONNAIRE Name (first, middle initial, last) Address City, State, Zip Social security number Michigan SportsMedicine and Orthopedic Center Your family physician address phone John K. Anderson, MD John K. Morris, MD Orthopedic Surgery Physical Therapy Sports Fitness 4972B Clark Rd. Suite 200 Ypsilanti, MI Fax of birth Ethnic Origin: White Black or African American Sex Age Asian Native Hawaiian or Pacific Islander Marital Status Home phone # Mobile phone # of injury American Indian or Alaskan Native Hispanic or Latino Origin or Descent Emergency contact person Emergency phone Other HEALTH HISTORY Yes No Yes No Yes No Chronic Cough or Lung Problems Chronic Back Problems Circulation problems Shortness of breath at rest Excess Bleeding from Surgery Hard of hearing Shortness of breath with exercise History of Anemia (low blood count) Wear glasses/contact lenses Recent cold, bronchitis or pneumonia Diabetes, since Problems walking History of Asthma or Wheezing Liver Disease/Jaundice/Hepatitis Chemotherapy High Blood Pressure - how many years? Kidney Disorder Immunizations up to date Hear Attack - Stomach Ulcer Are you on a special diet? Hear Failure - Chronic Heartburn Problems with food, chewing or swallowing Chest Discomfort/Tightness with exercise Hiatal Hernia Substance Abuse: Irregular Heart Beat - Transfusion - Alcohol Drinks per week Mitral Valve Prolapse Could you be pregnant? Years smoked packs/day Heart Murmur Last menstrual period - stopped smoking Stroke/TIA/Weakness/Paralysis Dentures/bridges/caps Height Epilepsy/seizures - of last seizure Skin problems Weight An exam by a cardiologist (heart doctor) If yes, Dr. s Name City Year Heart Catheterization If yes, where Year Excercise Stress Test If yes, where Year Ultrasound of Heart (Echocardiogram) If yes, where Year Pacemaker If yes, where Year Please list all previous hospitalizations (surgery, childbirth, medical illness) (approx. year) Reason Place (hospital or city) Patients under 18 must be accompanied by a parent or guardian Page 1 of 3

2 MEDICINE / ALLERGY AND HEALTH INFORMATION What are you being seen for today? o Right o Left Have you ever been rejected as a donor of blood or plasma? o No o Yes If yes, why? Have you ever tested positive for Hepatitis or the AIDS virus? Are you allergic to: Yes No Reaction Latex o o Any food? o o Iodine on your skin? o o Adhesive tape? o o Any medications o o Please list medication allergies here: Please list all medications you are presently taking, prescription and non-prescription (including dosage and frequency), also list antacids used (Tums, Maalox, Mylanta): Medication Dose Times per day Have you had any serious problems with anesthesia? If so, what? o Yes o No Has any blood relative of yours ever had any problems with anesthesia? o Yes o No Are there any personal/religious reasons you would refuse a blood transfusion? o Yes o No Has your physician told you to take antibiotics before surgery and/or dental work? o Yes o No PLEASE READ CAREFULLY AND SIGN I have carefully read all questions and I certify that the information I have given is correct and complete to the best of my knowledge. of patient/legal guardian FOR OFFICE USE ONLY Patients under 18 must be accompanied by a parent or guardian Page 2 of 3

3 FAMILY HISTORY Patient Name: of Birth: Please check any of the following diagnoses if it applies to your family members. Mother: o Cancer o Heart Disease o Stroke o Diabetes I of II o Asthma o Other Father: o Cancer o Heart Disease o Stroke o Diabetes I of II o Asthma o Other Sister(s): o Cancer o Heart Disease o Stroke o Diabetes I of II o Asthma o Other Brother(s): o Cancer o Heart Disease o Stroke o Diabetes I of II o Asthma o Other Grandparents: o Cancer o Heart Disease o Stroke o Diabetes I of II o Asthma o Other If other, please specify: of Patient/Legal Guardian of Patients under 18 must be accompanied by a parent or guardian Page 3 of 3

4 INSURANCE INFORMATION Michigan SportsMedicine and Orthopedic Center Primary Insurance - Name of your insurance carrier: Policy Holder s Social Security #: Secondary Insurance - Name of your insurance carrier: Third Insurance - Name of your insurance carrier: John K. Anderson, MD John K. Morris, MD Orthopedic Surgery Physical Therapy Sports Fitness of Birth: of Birth: of Birth: 4972B Clark Rd. Suite 200 Ypsilanti, MI Fax You must have a referral for each date of service from your primary care physician (if your insurance requires one). This is your responsibility. Do you have a co-pay? o Yes o No If yes, amount: WORKERS COMPENSATION PATIENTS We can only bill your company when you provide us with a written authorization from your employer. Without this your appointment may be rescheduled. Name of company: Address: City: Person to contact: of injury: County of injury: State, Zip: Phone number: Patients that have non-participating insurance: Payment is expected at the time of service unless prior arrangements have been made. All co-pays are expected at the time of service. We accept personal checks, cash, mastercard and visa. Page 1 of 2

5 ALL PATIENTS Where were you injured? How were you injured? of injury: Medicare Lifetime Authorization I request payment of authorized Medicare benefits to be made either to me or on my behalf to Michigan SportsMedicine and Orthopedic Center for any services furnished me by them. I authorize any holder of medical information about me to release to the health care financing administration and its agent any information needed to determine these benefits payable for related services. ALL PATIENTS Please sign so we may release information to your insurance company. Authorization ti release information: I hereby authorize Michigan SportsMedicine and Orthopedic Center to furnish my insurance carrier, including Medicare if applicable, any information that they may request concerning my treatment or information acquired in the course of my examination or hospitalization. Your medical insurance is a contract between you and your insurance company. We are not a party to this contract. Michigan SportsMedicine and Orthopedic Center will submit all claims for charges to your insurance provider as a service to you. Co-pays must be paid at the time of service in order to abide by your insurance contract. If your policy requires a referral, be sure to have it with you when you come to our office. Failure to obtain and present this at the time of service may result in a loss of benefits. If this occurs you will be responsible to pay all fees. I understand that I am financially responsible for payment of all services not covered by my insurance carrier. During the course of your treatment it may be necessary for your to undergo surgery. CMS Regulations require that you be informed that Dr. Anderson has ownership in Forest Medical Health Center. Please know that you have been referred to this facility without regard to ownership, and that you may seek care at alternative medical facilities. Page 2 of 2

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