Welcome to the UW Health Sports Medicine Clinic
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- Marlene Singleton
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1 Welcome to the UW Health Sports Medicine Clinic You are scheduled on to see. In order to best serve your needs, please bring with you to your appointment the following: 1. Completed Questionnaire (enclosed) 2. Imaging Hand carry any plain x-rays, MRI scans, CT scans, etc. that you may have had done at another facility. Radiology reports are not sufficient; we need the actual film and report. Typically, we require the x-rays to be 1 year old or less. If your insurance will not allow films to be done here, you may want to have new ones done at your clinic. 3. Medical Records Please bring any previous operative notes. 4. Insurance Referral (if needed) If you belong to an HMO, bring a copy of your referral with you. If this is a worker s compensation claim, bring the claim number, the name of the insurance company and the address where the claim should be sent. If you have any questions regarding your upcoming appointment, please do not hesitate to give us a call at (608) Directions The Sports Medicine Clinic is located at the UW Health Research Park Clinic, 621 Science Drive, Madison, Wisconsin, (608) Fax (608) From the east take Mineral Point Road west and turn left on Science Drive (before Whitney Way). From the west take Mineral Point Road east, turn right on Whitney Way and left on Science Drive. From the beltline (12&18) take Whitney Way exit north, go straight through intersections of Odana and Tokay and turn right on Science Drive.
2 Welcome to the UW Health Sports Medicine Clinic To help you better prepare for your clinic visit with us, please review the following information. This comprehensive list outlines what to expect, as well as the health care providers you may encounter at a typical clinic visit. Your visit with us may or may not include all of the services listed below. Thank you again for choosing the UW Health Sports Medicine Clinic as your health care provider. 1. Check-in and Waiting Area: Registration/check-in will be as you enter the clinic building. After checking in, proceed to the second floor waiting area. If you are new to our clinic and have not filled out the patient health history questionnaire, please obtain one at the second floor information desk. 2. Electronic Medical Record Update: A medical assistant or licensed athletic trainer (MA or LAT) will bring you from the waiting area and take you to your clinic room. The MA or LAT will then update your current medications and health status in your electronic medical record. 3. Preliminary Examination: You may first be seen by the physician s resident, physician assistant, nurse practitioner, licensed athletic trainer, or physical therapist, who will note your history, perform a preliminary physical examination, and determine if you need radiographic films. 4. Radiology: If you need new x-ray films, you will be sent down the hall to radiology. You may be asked to change into shorts or a gown for x-rays. You will then return to your clinic room. Your films will be sent electronically to your room; you do not need to hand-carry any films. 5. Physician Evaluation & Assessment: The physician will review your history and repeat essential parts of the physical examination. At the completion of this assessment, the physician will provide you with a diagnosis and a comprehensive treatment plan. This plan may include, but is not limited to, the following: o Prescription for braces/orthotics: Depending on the type of orthotic prescribed, you may see the orthotic technician at your clinic visit or you may be asked to schedule an appointment at a later date. o Consult for sports rehabilitation: You may schedule a sports rehabilitation appointment at any provider who is covered by your insurance. o Referral to other health care providers: Contact information will be provided at your clinic visit. Appointments may be scheduled at the Sports Medicine Clinic check-out desk, or you may be directed to schedule them on your own. o Follow-up appointment: Proceed to the Sports Medicine Clinic check-out desk to schedule your next appointment. Any doctor orders will have been sent to them electronically. **Please allow approximately 90 minutes for your initial clinic visit.**
3 Welcome! Telephone Availability Welcome to our clinic. Thank you for the opportunity to be a partner in your health care. At UW Health we strive to provide the best possible care. Our clinic is part of the University of Wisconsin. In addition to your physician, nurse practitioner or physician assistant, you may be seen by a resident physician, medical student, athletic trainer or advanced practice nursing student. Feel free to call any time you have concerns about your health. If you call the clinic before 4 p.m. we will make every effort to respond that day. If your call is urgent, we will review your needs and arrange for care. To respect your privacy, we will not leave information on answering machines or share information regarding patients over the age of 18 without their permission. After Hours Care Prescriptions In the event of an emergency, call 911. For urgent questions or concerns, please call (608) You will be connected to the answering service. They will contact the physician on call. Our doctors admit patients to UW Hospital. Before you run out of a prescribed medication, you can renew as follows: 1. Ask your doctor during your appointment. 2. Call your pharmacy, who will contact your doctor for you. Please contact your pharmacy at least 48 hours before your medication runs out. Lab Work/Tests You will be contacted with your test results within 14 days unless your doctor tells you otherwise. If you have not received your test results after two weeks, please call the clinic at (608) Appointments Outpatient Attendance Please schedule your return appointment before leaving. If you have questions or concerns before your next scheduled appointment, don't hesitate to call the clinic. If you have changes in your medication, allergies or current health, please share with your provider at your next scheduled appointment. If you need to cancel an appointment, please call us as soon as possible. This allows us to meet the needs of other patients. Please contact our registration department at (608) with any changes of address or insurance. We require verification of information through registration every 120 days. Contacting our registration department before your appointment will prevent delays. Resources Questionl Concern Resource Contact Information Insurance Please call your insurance company to verify coverage for therapy services. Billing Patient Billing Service (608) or (866) Pricing Priceline (608) Financial Hardship Community Care Line (608) or (866) Other Questions Patient Relations (608) On-Line prescription renewal Pharmacy uwhealth.org/rx ~ealth Univer~tyof~sconsin 621 Science Drive Sports Medicine.. (608) uwspommediclne.org PO-RPSPORTSCLINWELC (PO REV 07/28/08) Not To Be Filed In Medical Record
4 Patient Name: DOB: MR #: University of Wisconsin Hospital and Clinics 621 Science Drive Madison, Wisconsin Date: PATIENT HEALTH QUESTIONNAIRE Age: Height: in/cm Weight: lbs/kg Primary Care Physician: Referring Physician: MAIN CONCERN / CHIEF COMPLAINT What problem can we help you with today? Have you already been given a diagnosis? Yes No If yes, what was the diagnosis? HISTORY OF PRESENT ILLNESS What was the date of injury? Or How long have you had this problem? Rate your pain on a scale of 0 to 10 (0=no pain, 10= worst pain you ever had) Today: At its worst: Please rate the level to which you feel the following activities are affected by your current problem. (0 = no effect, 10 = unable to perform) Sports: Work: Sleep: Daily activities: Would you describe your pain as: (Check all that apply) constant on/off sharp dull achy burning pressure tingling/electrical Do you have any of the following associated symptoms (Check all that apply): muscle weakness loss of range of motion locking/catching feeling of giving way/dislocation tenderness to touch limp swelling numbness/tingling What else have you tried for treatment and/or pain control? Circle Y/N to indicate if these were helpful. Rest Y/N Ice Y/N Ibuprofen (advil/motrin)y/n Aspirin Y/N Tylenol Y/N Aleve (naproxen) Y/N Splint/brace Y/N Physical therapy Y/N Other (please list) Y/N What makes your pain worse? Since your diagnosis/injury, check the activities that are painful/diffi cult: moving in bed positional changes turning/twisting sitting standing shopping/banking yard work meal prep housekeeping driving/car riding Has any other medical provider seen you for this problem? Yes No Have you had an x-ray for this problem? Yes No Have you had an MRI or Ultrasound for this problem? Yes No Have you had an EMG for this problem? Yes No Where were these performed? UWH# (REV. 01/10/11 SR) Scan to Questionnaire-Health PATIENT HEALTH QUESTIONNAIRE Page 1 of 2
5 Patient Name: DOB: MR #: REVIEW OF SYSTEMS Please circle any of the symptoms you are currently experiencing. General Weight Loss Fevers/Chills Fatigue Gastrointestinal Heartburn Nausea/Vomiting Abdominal Pain Liver problems Cardiovascular Chest pain Palpitations Respiratory Cough / short of breath Genitourinary Kidney problems Painful urination Skin Skin Rash / redness Skin wound Neurological Headaches Dizziness Psychosocial Depression Anxiety Sleep Disturbance Ears/Nose/Throat Hearing loss Hoarseness Congestion Hematologic Easy bleeding Easy bruising HIV/AIDS Endocrine Diabetes Thyroid problems Eyes Vision Problems PAST SURGICAL HISTORY Have you had previous surgeries? If yes, what? 1. Right Left Body Part: Surgeon: Year: 2. Right Left Body Part: Surgeon: Year: PAST MEDICAL HISTORY Do you have or have you ever had any of the following? High blood pressure Heart disease/heart attack Heart/Bypass surgery Angioplasty Blood clots Diabetes Kidney disease Asthma COPD/Emphysema Tuberculosis Seasonal allergies Stomach ulcers Acid refl ux/heart burn Arthritis Cancer Hepatitis Migraine headaches Stroke Rheumatoid arthritis/lupus/autoimmune disease (circle) FAMILY HISTORY Do any of your close relatives have any bone or joint problems? Yes No If yes, what problems do they have? SOCIAL HISTORY Do you smoke? Yes No How many packs/day? How long? years Do you drink alcohol? Yes No How many drinks per week? What is your occupation? Are you currently working? Yes No If yes, are you on light duty? Yes No Is this a Workers Compensation injury? Yes No Completed by: Date: If not completed by patient, relationship to patient: Reviewed by: Date: Time: UWH# (REV. 01/10/11 SR) Scan to Questionnaire-Health PATIENT HEALTH QUESTIONNAIRE Page 2 of 2
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Locations 1 Central 601 West Second Street, Bloomington, IN 47402 t 812.353.9484 800.934.6074 2 East 328 S. Woodcrest Drive, Bloomington, IN 47401 t 812.353.3278 866.353.3278 3 West 2499 W. Cota Drive,
PATIENT INSURANCE AUTHORIZATION WORKSHEET
PATIENT INSURANCE AUTHORIZATION WORKSHEET We accept all insurances that have in-network and out-of-network benefits. If you do not have insurance benefits for physical therapy, please call us at 858-457-3545
Patient Checklist. Expect to pay your co-pays and non-covered services on the day of service.
Welcome to Cedar Run Eye Center. We look forward to your visit with us! Enclosed you will find: Registration Form History Form Patient check list with a map on the back side Patient Name: Date of Appointment:
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE DEMOGRAPHICS- To be completed by all patients Patient Name: Today s Date: / / Patient Address: _ City: State: Zip: Home Phone #: ( ) - Work #:
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient's Name: City: State: Zip Code: Phone: Marital Status: Spouse/Care Giver Name: Phone (H) (W) Occupation:
Orthopedic Specialists Of SW FL New Patient Information Form
Orthopedic Specialists Of SW FL New Patient Information Form Patient Name: DOB Age M or F SS# Home Ph# Cell Ph# Work# Local Address City/State Zip Code Northern/Other Address City/State Zip Code Reason
CHIEF COMPLAINT (No, you can't just say your "husband" or "wife")
Date: / / Patient s Full Name: Home Phone: Cell Phone: E-Mail: Male Female Age: Date of Birth: / / Social Security #: - - Address: City: State: Zip: How would you like to be addressed by our staff? Married
RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form
Intake Form : Personal Information please print clearly Name: last first middle initial Home Address: Home Telephone: ( ) Cell Phone: E-Mail Address: Social Security #: of Birth: Age: Sex: M F Marital
NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
PATIENT REGISTRATION
PATIENT REGISTRATION NAME: HOME ADDRESS: CITY, STATE, & ZIP CODE: HOME PHONE: CELL: WORK: SOCIAL SECURITY NUMBER: SEX: MALE/FEMALE DATE OF BIRTH: AGE: EMERGENCY CONTACT: RELATIONSHIP: EMERGENCY CONTACT
LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP OCCUPATION EMPLOYER/SCHOOL WORK PH
PLEASE PRINT PATIENT INFORMATION TODAY S DATE: LAST NAME FIRST MI AGE ADDRESS APT CITY STATE ZIP E-MAIL HOME CELL OCCUPATION EMPLOYER/SCHOOL WORK SOCIAL SECURITY NO SEX: M / F DATE OF BIRTH MARITAL STATUS:
WELCOME TO TRI-COUNTY EYE CLINIC
WELCOME TO TRI-COUNTY EYE CLINIC Thank you for choosing Tri-County Eye Clinic as the provider for your eye care. You have an appointment at one of the following two locations: 15122 Dedeaux Road, Gulfport,
Physical Rehabilitation Center Outpatient Therapy Medical History Goals and Consent for Treatment
Goals and Consent for Treatment The Physical Rehabilitation Department is here to provide you with the highest quality of care. We treat every patient fairly and with respect, and make sure to protect
Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) 395-6450 FAX (757) 622-2750 INTERNET www.beachpain.com **MEDICATION GUIDELINES PRIOR TO PROCEDURES
CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) 395-6450 FAX (757) 622-2750 INTERNET www.beachpain.com MARTIN V.T. TON, MD Please call us at 395-6450 at least 24 hours in advance if you cannot make
Creekside Physical Therapy and Rehabilitation
Creekside Physical Therapy and Rehabilitation PATIENT INFORMATION Patient s Name: Social Security #: Age: Sex: M/ F Date of Birth: Email: Home Address: City: State: Zip: Telephone (Hm): Work: Mobile: Employer:
RALEIGH NEUROSURGICAL CLINIC, INC.
Revised 09/26/14 PATIENT INFORMATION RALEIGH NEUROSURGICAL CLINIC, INC. Age: Sex: M F Date Last Name First Name Middle Initial Mailing Address City State Zip Social Security # Home Phone ( ) Cell Phone
Denver Spine Surgeons David Wong, MD, Sanjay Jatana, MD, Gary Ghiselli, MD
Cervical and Lumbar Spine Health History Name: Today s Date: Referring Provider: How did you find us: (Please circle) Primary care physician, Google search, Facebook, Friend or Family member, Website (JatanaSpine
Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone
DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address
LIST ALL MEDICATIONS (BOTH PRESCRIBED AND OVER THE COUNTER) AND SUPPLEMENTS
PLEASE PRINT PATIENT LAST NAME: FIRST NAME DATE OF BIRTH: / / AGE: ADDRESS: APT CITY STATE ZIP HOME PHONE # CELL PHONE # WORK PHONE # SEX M F MARITAL STATUS DRIVER S LICENSE # SOCIAL SECURITY # - - EMPLOYER
PATIENT INTAKE FORM Pennsylvania Chiropractic and Rehab, LLC Dr. Jason Cozart. OOB Age _
PATIENT INTAKE FORM Pennsylvania Chiropractic and Rehab, LLC Dr. Jason Cozart Patient Name: Date: OOB Age Address City, State, Zip Home Phone Work Phone Other em ail address M or F Marital --~------- Status
Orthopaedic Institute of Ohio Demographic Information Date:
Orthopaedic Institute of Ohio Demographic Information Date: Patient Name Home Phone Cell Phone Employer Phone Mailing Address (include PO Box and Apt. #) Family Doctor Name and Phone Number City, State,
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Hello, Please note: The following information will be needed at your appointment:
Hello, You are receiving this mailing because you or a family member have an upcoming appointment at the Albany Medical Center s Neurology Group as noted above. Our goal is to provide you with the best