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1 Date New Patient Packet Address Social Security Number D.O.B Patient's Last Name Patient's First Name Middle Initial Age: Home Phone: Cell Phone: Work Phone: Address Male/Female: Single/Married/Divorced/Widowed Emergency Contact Phone # City, State, Zip Employer: Work Phone: Primary Insurance: Policy Holder: Date of Birth Secondary Insurance: Policy Holder: Date of Birth IF PATIENT IS MINOR: Responsible Party: Relationship D.O.B Home Phone: Primary Care MD: Referred by: My Primary MD Employer: Height (ft,in) Weight (lbs) ' '' How did you hear about us? Page 1 of 8

2 OFFICE POLICIES * I understand that I am responsible for any patient portion due that is not contractually covered by the agreement between my insurance company and The Dungy Orthopedic Center. * I authorize payment of surgical and/or medical benefits for services rendered. * I understand that payment in full is expected at the time of service. If it becomes necessary for my account to be referred to a collection agency I understand that I am responsible for the collection fees that will be added to my balance. * I understand if I No Show for my appointment or cancel on the same day as my appointment there is a $25 charge. * I understand that medication refills are done Monday thru Friday during business hours. * I authorize the release of medical and financial information to my insurance company as well as the following individuals Patient Signature or Responsible Party Print Name and Date NOTE: PLEASE BRING ALL X-RAYS AND MEDICAL RECORDS CONCERNING YOUR CONDITION. WE NEED THE ACTUAL FILMS SINCE CD S ARE NOT CONSIDERED DIAGNOSTIC QUALITY. Please list only your primary complaint: Reason for visit: Chief Complaint Left Right Both Does not apply The symptoms are best described as: Throbbing Shooting Worse at night Dull Stabbing Achy Sharp Difficult to describe Do you have any other problems? (Check all that apply) I have no other symptoms Associated Symptoms Numbness Buckling Redness Locking Giving Way Tingling Weakness Bruising Catching Discharge Popping Drainage Swelling Grinding Discoloration Alleviating Factors Does any of the following improve your symptoms? (Check all that apply) Nothing improves my symptoms Sitting Bracing Standing Ace Wrap Lying Down Ice Heat Elevation Page 2 of 8

3 Exacerbating Factors Does any of the following worsen your symptoms? (Check all that apply) Nothing worsens my symptoms Sitting Walking Standing Throwing Lying Down Squatting Stairs Kneeling Interventions Please indicate any specific interventions you may have tried: I have not had undergone any of these interventions Chiropractic Intervention Physical Therapy Steroid Injection(s) Other Injections Anti-Inflammatories Helped Did Not Help Made Worse Have not tried Describe the condition. Include the following: What? When? How? Why? How Long? How it's been treated? HPI I have additional issues I would like to discuss (please be as detailed as you can): Page 3 of 8

4 Past Medical History Do you or have you ever had any of the following? (check all that apply) I have no medical problems Stroke Tuberculosis Rheumatoid Arthritis Bleeding Disorders Hypertension Inflammatory Bowel Disease Osteoarthritis Blood Clots Heart Attack Seizures Polio Bronchitis Heart Valve Disease Asthma HIV or AIDS Anxiety Heart Rhythm Problems Urinary Tract Infections Diabetes Anemia Stomach Ulcers Mental Illness Hypothyroidism Gout Kidney Disease Alcoholism Low Back Pain Neuropathy Hepatitis Depression Blood Transfusions COPD Cancer- What kind? I am currently pregnant Lung Disease Please give details on anything you have checked: Past Surgical History If you have undergone surgery, please give details below: I have never undergone surgery Medications None Medications are entered in the Rx Ability Medications reviewed and updated, see medication list Page 4 of 8

5 Please list any medications you are currently taking, as well as how much and how often: Allergies Allergies are entered in the Patient ability in the Allergies Table None Allergies reviewed and updated, see allergies list Please list any known allergies, including any drug allergies: Family History Has anyone in your family had any of the following? (check all that apply) There are no medical problems in my family Stroke Tuberculosis Rheumatoid Arthritis Hepatitis Hypertension Inflammatory Bowel Disease Osteoarthritis Neuropathy Heart Attack Seizures Polio COPD Heart Valve Disease Asthma HIV or AIDS Lung Disease Heart Rhythm Problems Urinary Tract Infections Diabetes Blood Transfusions Stomach Ulcers Mental Illness Hypothyroidism Bleeding Disorders Kidney Disease Alcoholism Low Back Pain Blood Clots Anemia Depression Anxiety Bronchitis Cancer - What kind(s): Gout Please give details for anything checked above: Social History Work Status: Working Retired Disabled A Student A Homemaker Page 5 of 8

6 Current or most recent occupation: Marital Status: Married Single Divorced Separated A widow Tobacco Use: How Many? How long? I quit smoking after smoking I currently smoke cigarettes - how much? I have never smoked I smoke a pipe I smoke a cigar I chew tobacco Alcohol Use: I never drink I drink rarely I drink socially I am an alcoholic I am a recovering alcoholic Drug Use: Never Currently In the past Please check all that apply: I do not have any of the problems listed below Review of Systems Fevers Intolerance to stairs Urinary Frequency Weight gain Chills Heart Palpitations Painful Urination Difficulty Hearing Nausea Heartburn Swollen Legs Difficulty Swallowing Vomiting Stomach Pain Calf Cramps Runny Nose Headaches Dark, Tarry Stools Poor Appetite Depression Dizziness Blood in Stools Claustrophobia Weight Loss Lightheadedness Wheezing Metallic Implants Shortness of Breath Visual Changes Diarrhea Metal in eyes Urinary Retention Chest Pain Constipation Page 6 of 8

7 THE DUNGY ORTHOPEDIC CENTER YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION 1. You can request that our practice communicate with you about your health related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. We will accommodate all reasonable requests. 2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your information to only certain individuals involved in your care or the payment for your care such as family members and friends. We are not required to agree to your request; however if we do agree we are bound by our agreement except when otherwise required by law. 3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not to include psychotherapy notes. You must submit your request in writing to Dungy Orthopedic Center. 4. You may ask us to amend your health records if you believe the information is incorrect or incomplete. To request an amendment your request should be made in writing to your physician. You must provide us with a reason that supports your request. 5. You are entitled to receive a copy of this notice. You may ask us for a copy at any time. To obtain a copy of this notice contact our front office. 6. If you believe your privacy rights have been violated you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our office contact the Office Manager at All complaints must be submitted in writing. You will not be penalized for filing a complaint. 7. Our practice will obtain written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. This notice describes how health information about you as a patient may be used and disclosed and how you can gain access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).. Patient Signature Date Page 7 of 8

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