I t / I _ I Subscriber's Name. I I Subscriber's Name ('LAST) (FIRST) (MI) 1 Name of Attorney Phone ( ) How Accident Occurred

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1 Date Next Gen # Dr. Axe Dr. Brady Dr. Hershey Dr. Johnson Dr. Katz Dr. Moran El Dr. Pushkarewicz El Dr. Rudin Dr. Steele Dr. Bodenstab fl Dr. Crain El Dr. Hogan El Dr. Kahlon Dr. Kim fl Dr. Newcomb El Dr. Raisis fl Dr. Sowa Name Address Development CityStatelZip (LAST) (FRST) (M) Home phone ( ) Cell ( ) Family Doctor Phone ( ) Referring Dr. Phone ( ) How did you hear about us? Referring Attorney Name Male Date of birth Age Female Single Married 17 Divorced Widowed Relationship to responsible person Social Security No. Occupation Employed by Business phone ( ) Name Address - Development CityStatelZip Home phone ( ) (LAST) (FRST) (M) Social Security No. Relationship to Patient Occupation Employed by Business phone ( ) Subscriber's Name ('LAST) (FRST) (M) * CT u lnsurance Go. Name CT lnsurance Go. Address _ Subscriber's Name t / 0 Patient's.D. No. Group/Account No. Relationship to patient Date of birth Social Security No. Patient's.D. No. (LAST) (FRST) (M1 Group/Account No. lnsurance Co. Name Relationship to patient lnsurance Go. Address - Date of birth CityStatelZip Social Security Vo. (J Box) AUTO ACCDENT U WORK RELATED NJURY PERSONAL NJURY lnsurance Go. Name lnsurance Go. Address CityStatelZip lnsurance Co. phone ( ) Date of njury State in which injury occurred Claim No. (Complete the following if accidental injury) Name of Adjuster Where Accident Occurred 1 Name of Attorney Phone ( ) How Accident Occurred Tech Graphics (302) Firs1 Stew Onhamedrs

2 You may communicate with the following individuals about my care: Name Relationship Phone # The First State Surgery Center and Spine Care Delaware are Ambulatory Surgery Centers owned and operated by Physicians of First State Orthopaedics. While our outpatient surgery centers are an appropriate site for your surgical procedure, there are other facilities in the area where such procedures could also be performed. 'There will be a separate facility fee for surgeries performed at First State Surgery Center or Spine Care Delaware as there would be from any other facility. First State Orthopaedics, P.A., employs board certified physician assistants who are trained to perform the duties of a first assistant at surgery and to assist in the office. Our billing to your insurance carrier may include a fee for the physician assistant. accept responsibility to insure that payment is made for all services rendered on my behalf. understand that my insurance policy is a contract between me and my insurance company and that am responsible to First State Orthopaedics, P.A., for all fee balances determined to be patient responsibility. acknowledge that it is also my responsibility to obtain a referral from my PCP if required or will be responsible for payment of FSO fees. hereby authorize and direct payment to First State Orthopaedics, P.A., for surgical and/ or medical benefits, if any otherwise payable to me under the terms of any applicable insurance. authorize the release of any medical information necessary to process claims. hereby authorize photocopies of this form to be as valid as the original. First State Orthopaedics, P.A., is hereby authorized to take any legal action which may be necessary either in law or in equity in my name against any insurance company for any and all fee balances, and covenant and agree to cooperate fully with First State Orthopaedics, P.A., in the presentation of such claims and to furnish all papers and documents necessary in such proceedings and to attend court and testify if First State Orthopaedics, P.A., deems such to be necessary. n the event of default on any payment due First State Orthopaedics, P.A., which are my responsibility, agree to pay a cost of collection including attorney fees. Balances not paid within 90 days are subject to collection procedures and a collection fee. f the patient is a minor, the parent or legal guardian must sign Signature of patient, parent or legal guardian Date " request that payment of authorized Medicare benefits be made on my behalf to First State Orthopaedics, P.A., for any services furnished me by that physician(s). authorize any holder of medical information about me to release to the Center for Medicare and Medicaid Services (CMS), which oversees the Medicare program, and its agents any information needed to determine these benefits or the benefits payable for related services." Signed: Medicare Beneficiary Date

3 CERVCAL SPNE NTAKE FORM Date: Name: Age: FSO MR #: REASON FOR VST - Ort Home Body Part(s): Right Left Bilateral Complaint: Pain njury Fracture Numbness Swelling Have you been off work for this problem?: Yes No Dates off work: Doctors who have treated you for this problem: Did that doctor refer you here?: Yes No Diagnostic tests and treatment performed (please list when/where/what) : X-Ray MR njection Surgery: NSADS (anti-inflammatories) EMG CT/Scan Bone Scan Lab Work Other: PT Have you ever had similar problems? f yes, please give details: HSTORY OF PRESENT NJURY - Ortho OV>Specialty HP>Cervical Spine (Describe your pain, please check all that apply) Onset of Pain: Wk(s) Mo(s) Yr(s) Severity : 1 (little pain) (excrutiating pain) Date of njury: Auto Accident Workers' Comp Work Status: Currently working hrs/wk Not working Status of Pain: mproved No change Worse Resolved Frequency of Pain: Daily Constant ntermittent Occasional Location of Pain: Pain Resolved Radiation of Pain: None Weakness: None Numbness/Tingling: None R L BL R L BL R L BL R L BL Neck Neck Wrist Neck Arm Trap Arm Trap Shoulder Shoulder Shoulder Shoulder ntrascap Elbow Hand Elbow Other: Arm Finger Arm Hand Elbow Hand Other: Other: Other: Quality of Pain: Aggravated By: Relieved By: Associated Symptoms/ Severe Lifting Changing Positions Pertinent Negatives: Aching Sitting Sitting Balance Disturbances Shooting Driving Heat Bladder ncontinence Dull Office Work Exercise Bowel ncontinence Resolved Sleeping Medication: Spasms Other End of Day Rest Gait Disturbances Context Mornings Stretching Change in Handwriting Symptoms mproved With: Other: Other: Difficulty w/ Fine Motor Control PT njections Time Meds Other: Symptoms Failed to mprove With: PT njections Time Meds Please check the box below that best describes your pain: Neck Pain = Arm Pain Neck Pain > Arm Pain Neck Pain < Arm Pain REVEW OF SYSTEMS - Ortho OV>Add Additional ROS>ROS Defaults>Globally Normal Ortho Do you have any of the following symptoms? Constitutional: Metabolic/Endocrine: Neurological: mmunological: Fatigue Cold ntolerant Difficulty Walking Enviromental Allergies Fever Heat ntolerant Dizziness Food Allergies Night Sweats HEENT: Hematologic/Blood: Cardiovascular: Headache Bleeding Chest Pain Vision Loss Respitory: Cyanosis (blue coloration of skin) rregular Heartbeats/Palpatations Gastrointestinal: Constipation Cough Dyspnea ntegumetary/skin: Diarrhea Genitourinary: Rash Nausea Dysuria Vomiting Hematuria None OVER Page 1

4 PATENT'S MEDCAL CONDTON - Assistant Doc>Vital Signs Height: ft in Weight: lbs. My Weight in the last 6 months has: Not Changed ncreased lbs. Decreased lbs. Please list details of any special diet program: Have you ever taken any anti-inflammatories/arthritis medications?: Yes No (ex: Naprosyn/buprofen) f yes, please list: Reaction: Reaction: Allergy & Reaction: Aspirin NSADs Codeine V Dye ALLERGES - Assistant Doc>Add Allergy (anti-inflammatories - ibuprofen, naprosyn) Narcotics (Percocet, Vicodin) Penicillin Other: Latex Sulfa No Known Drug Allergies PATENT'S MEDCAL HSTORY - Histories>Additional History ADS/HV COPD (Emphysema) High Blood Pressure Parkinson Disease None Alcoholism Coronary Artery Disease Hyperthyroidism Peptic Ulcer Disease Alzheimers Crohn's Disease Hypothyroidism Psoriasis Other: Anemia Degenerative Joint Disease nflammatory Bowel Disease PVD Angina Depression Juvenile Rheumatoid Arthritis Renal Disease Arthritis Diabetes Kidney Disease Rheumatoid Arthritis Asthma Drug Abuse Liver Disease Scoliosis Atrial Fibrillation DVT (Blood Clot) Lyme Disease Seizure Disorder Benigin Prostatic Hyertrophy Fibromyalgia Migraine Headaches Sleep Apnea Cancer Gallbladder Disease Multiple Sclerosis SLE (Lupus) Cerebrovascular Accident GERD Myocardial nfarction Spinal Stenosis (Stroke) Gout Obesity Thyroid Disease Congestive Heart Failure Hepatitis Osteoarthritis Valvular Disease (CHF) High Cholesterol Osteoporosis (Heart valve problems) PATENT'S SURGCAL HSTORY - Histories>Additional History ACL Surgery CABG Hip Replacement Pacemaker Other: Angioplasty Cardiac (Heart) Valve Knee Replacement Small Bowel Resection Angio w/stent Replacement Laminectomy Thyroidectomy Appendectomy Carpal Tunnel Release LASK Tonsillectomy Athroscopy (Scope) Details: Cataract Extraction Meniscus Surgery Gender Specific Cholecystectomy Muscle Biopsy Female (gallbladder removal) Neck Surgery - Details: Cesarean Section Back Surgery - Details: Colectomy Hysterectomy Colostomy Mastectomy Discectomy Male Gastric Bypass Prostatectomy Hernia Repair ORF TURP None PATENT'S FAMLY HSTORY - Histories> Additional Family History s your Father Living? Yes No s your Mother Living? Yes No f no, age deceased cause of death f no, age deceased cause of death Are any of your brothers/sisters deceased? Yes No f yes, age deceased cause of death Family history of chronic/inherited diseases: PATENT'S SOCAL HSTORY - Histories>Social History Tobacco Use: Yes No Former/Year Quit Consume Alcohol: Yes No Former/Year Quit Activity Level: Sedentary Moderate Vigorous Type of Exercise: SGNATURE Date: Signature of Patient, Parent or Guardian: Page 2

5 LUMBAR SPNE NTAKE FORM Date: Name: Age: FSO MR #: REASON FOR VST - Ort Home Body Part(s): Right Left Bilateral Complaint: Pain njury Fracture Numbness Swelling Have you been off work for this problem?: Yes No Dates off work: Doctors who have treated you for this problem: Did that doctor refer you here?: Yes No Diagnostic tests and treatment performed (please list when/where/what) : X-Ray MR njection Surgery: NSADS (anti-inflammatories) EMG CT/Scan Bone Scan Lab Work Other: PT Have you ever had similar problems? f yes, please give details: HSTORY OF PRESENT NJURY - Ortho OV>Specialty HP>Lumbar Spine (Describe your pain, please check all that apply) Onset of Pain: Wk(s) Mo(s) Yr(s) Severity : 1 (little pain) (excrutiating pain) Date of njury: Auto Accident Workers' Comp Work Status: Currently working hrs/wk Not working Status of Pain: mproved No change Worse Resolved Frequency of Pain: Daily Constant ntermittent Occasional Location of Pain: Pain Resolved Radiation of Pain: None Weakness: None Numbness/Tingling: None R L BL R L BL R L BL R L BL Lower Back Buttock Hip Buttock Leg Thigh Leg Thigh Buttock Ankle Knee Ankle Groin Foot Foot Foot Other: Great Toe Ankle Great Toe Other: Other: Other: Quality of Pain: Aggravated By: Relieved By: Associated Symptoms/ Severe Bending Changing Positions Pertinent Negatives: Aching Changing Positions Sitting Balance Disturbances Shooting Lifting Laying Down Bladder ncontinence Dull Sitting Standing Bowel ncontinence Resolved Driving Heat Spasms Other Walking Exercise Gait Disturbances Standing Medication: Weakness Context Pushing Rest Change in Handwriting Symptoms mproved With: End of Day Stretching Other: PT njections Time Meds Mornings Other: Symptoms Failed to mprove With: Other: Please check the box below that best describes your pain: PT njections Time Meds Back Pain = Leg Pain Back Pain > Leg Pain Back Pain < Leg Pain REVEW OF SYSTEMS - Ortho OV>Add Additional ROS>ROS Defaults>Globally Normal Ortho Do you have any of the following symptoms? Constitutional: Metabolic/Endocrine: Neurological: mmunological: Fatigue Cold ntolerant Difficulty Walking Enviromental Allergies Fever Heat ntolerant Dizziness Food Allergies Night Sweats HEENT: Hematologic/Blood: Cardiovascular: Headache Bleeding Chest Pain Vision Loss Respitory: Cyanosis (blue coloration of skin) rregular Heartbeats/Palpatations Gastrointestinal: Constipation Cough Dyspnea ntegumetary/skin: Diarrhea Genitourinary: Rash Nausea Dysuria Vomiting Hematuria None OVER Page 1

6 PATENT'S MEDCAL CONDTON - Assistant Doc>Vital Signs Height: ft in Weight: lbs. My Weight in the last 6 months has: Not Changed ncreased lbs. Decreased lbs. Please list details of any special diet program: Have you ever taken any anti-inflammatories/arthritis medications?: Yes No (ex: Naprosyn/buprofen) f yes, please list: Reaction: Aspirin Codeine V Dye Latex ALLERGES - Assistant Doc>Add Allergy Reaction: Allergy & Reaction: NSADs (anti-inflammatories - ibuprofen, naprosyn) Narcotics (Percocet, Vicodin) Penicillin Sulfa Other: No Known Drug Allergies PATENT'S MEDCAL HSTORY - Histories>Additional History ADS/HV COPD (Emphysema) High Blood Pressure Parkinson Disease None Alcoholism Coronary Artery Disease Hyperthyroidism Peptic Ulcer Disease Alzheimers Crohn's Disease Hypothyroidism Psoriasis Other: Anemia Degenerative Joint Disease nflammatory Bowel Disease PVD Angina Depression Juvenile Rheumatoid Arthritis Renal Disease Arthritis Diabetes Kidney Disease Rheumatoid Arthritis Asthma Drug Abuse Liver Disease Scoliosis Atrial Fibrillation DVT (Blood Clot) Lyme Disease Seizure Disorder Benigin Prostatic Hyertrophy Fibromyalgia Migraine Headaches Sleep Apnea Cancer Gallbladder Disease Multiple Sclerosis SLE (Lupus) Cerebrovascular Accident GERD Myocardial nfarction Spinal Stenosis (Stroke) Gout Obesity Thyroid Disease Congestive Heart Failure Hepatitis Osteoarthritis Valvular Disease (CHF) High Cholesterol Osteoporosis (Heart valve problems) PATENT'S SURGCAL HSTORY - Histories>Additional History ACL Surgery CABG Hip Replacement Pacemaker Other: Angioplasty Cardiac (Heart) Valve Knee Replacement Small Bowel Resection Angio w/stent Replacement Laminectomy Thyroidectomy Appendectomy Carpal Tunnel Release LASK Tonsillectomy Athroscopy (Scope) Details: Cataract Extraction Meniscus Surgery Gender Specific Cholecystectomy Muscle Biopsy Female (gallbladder removal) Neck Surgery - Details: Cesarean Section Back Surgery - Details: Colectomy Hysterectomy Colostomy Mastectomy Discectomy Male Gastric Bypass Prostatectomy Hernia Repair ORF TURP None PATENT'S FAMLY HSTORY - Histories> Additional Family History s your Father Living? Yes No s your Mother Living? Yes No f no, age deceased cause of death f no, age deceased cause of death Are any of your brothers/sisters deceased? Yes No f yes, age deceased cause of death Family history of chronic/inherited diseases: PATENT'S SOCAL HSTORY - Histories>Social History Tobacco Use: Yes No Former/Year Quit Consume Alcohol: Yes No Former/Year Quit Activity Level: Sedentary Moderate Vigorous Type of Exercise: SGNATURE Date: Signature of Patient, Parent or Guardian: Page 2

7 FRST STATE ORTHOPAEDCS ACKNOWLEDGMENT OF RECEPT OF NOTCE OF PRVACY PRACTCES hereby acknowledge that 1 have received a copy of First State Orthopaedics Notice of Privacy Practices. Print Name -- Signat~~re Date FOR OFFCE USE ONLY We attempted to obtain written acknowledgment of receipt of First State Orthopaedics Notice of Privacy Pract~ces but acknowledgment could not be obtained because: 0 ndividual refused to sign Communication barriers prohibited obtaining the acknowledgment U cl An emergency situation prevented us from obtaining acknowledgment Other ( Please Specify)

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