New Patient Questionnaire

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1 New Patient Questionnaire Name: Date: Age: Date of Birth: Right or Left Handed: Height: Weight Primary Care Doctor: Address and Phone number: Occupation (If working): Current work status (full duty, light duty, modified, etc.) List all medical illnesses: indicate with Y (yes) or N (no). Anemia Stomach Ulcers Leg Cramps Arthritis Excessive bleeding Phlebitis Asthma Heart Problems Rheumatic fever/murmur Birth Control Pills High blood pressure Liver Problems Circulation problems Hormone Therapy HIV or AIDS Diabetes Kidney Problems Thyroid problems Any others? List all previous surgeries, surgeon s name and approximate dates: List all current medications and doses: Allergies to medications or latex? Do you smoke? If so, how much? What is the main problem for which you are seeing us today?

2 New Patient Questionnaire When did you first begin to have this problem? Injury (or injuries) which you feel are related to the problem for which we are seeing you today? (Please indicate approximate dates) List names and dates of doctors you have seen for this problem: Treatments you have for this, (Medications, Therapies, Splints, etc.) dates: Have you had other treatments such as chiropractic, acupuncture, massage, etc.? Please list with dates: Was this a work related illness/injury or accident? Specific date of work illness/injury or accident? Was this illness/injury or accident the result of a motor vehicle accident? Specific date of motor vehicle accident? I certify that the information provided, here in, is true and correct to the best of my knowledge. Signature: Date:

3 PAIN QUESTIONAIRE Please mark the areas on the body diagram where you feel the described sensations: Ache ++++ Numbness Pain and Needles oooo Burning xxxx Stabbing ////

4 INSTRUCTIONS Rate your MAJOR AREA OF PAIN on the 0 10 Pain Rate Scale. Write the NUMBERS of your pain at the present time and your best day and worst day over the past 30 days. Remember, the number refer to your pain, not how strong or weak you feel. For example: Number 1 is a Minimal Pain and Number 7 is a Strong pain. 10 Excruciating; you need to call emergency services 9 Very, very strong pain 8 Very strong pain 7 Strong pain 6 Somewhat strong pain 5 Moderate pain 4 Somewhat moderate pain 3 Light pain 2 Very light pain 1 Minimal pain 0 No pain at all YOU RE PAIN RATE Pain Now OVER LAST 30 DAYS Best Day Worst Day

5 Welcome to Arapahoe Sports Medicine and Rehabilitation. We are glad that you are here and have entrusted us with your care. Everyone at Arapahoe Sports Medicine and Rehabilitation is committed to you and your health and together we will strive to get you back on the road to recover. What should I expect on my visit to Arapahoe Sports Medicine? On your first visit, we may ask you to fill out a brief new patient form which includes your basic demographic information: name, date of birth, telephone, emergency contact, medical history, and also information regarding insurance coverage or other billing issues. We will also provide you with a handout explaining our privacy practices. You will be evaluated by a physical/occupational therapist through physical testing and measurements, and by providing an oral history of the problem. You will also receive treatment by the therapist on your first visit. Please bring a photo I.D., your prescription for therapy, insurance card, and any anticipated copay monies. What should I wear to therapy? You should wear comfortable clothing, as you will be asked to lie on a mat and change positions occasionally for your treatment. We will usually require access to the skin of the affected area, so short sleeves or shorts are recommended for problems involving knees or elbow. How much time is involved? Your first visit should last 45 to 60 minutes; subsequent visits are approximately 30 to 60 minutes. Additional time may be required for an exercise program, either in our office or at home. If you are not able to attend scheduled or prescribed appointments please call to reschedule. Will you file my insurance? We will file your medical insurance or worker s compensation claim for you. We will also provide itemized statements to auto insurance companies, or to your attorney as requested by the patient. What should I expect to pay for therapy? Charges will vary depending upon your individual treatment plan. Typically charges for a visit will range from $70.00 to $ As a service to you, we will call your insurance company to verify your benefits for therapy and your ability to receive treatment at Arapahoe Sports Medicine and Rehabilitation. The information they provide will clarify your policy s coverage terms, limits, and your financial responsibility. We recommend that you obtain this information prior to your first appointment if you have any concerns about your coverage. Simply call the customer service number on your insurance card and ask for your coverage for additional physical therapy. Colorado Orthopedic Consultants, dba Arapahoe Sports Medicine and Rehabilitation Center 1411 S Potomac St, Suite W Hampden Ave., Suite 500

6 Aurora, CO Englewood, CO

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