8100 S. Walker – Building A, Oklahoma city, Ok 73139Phone (405) 632-4468 Fax (405)632-0436
PLEASE PRINTPATIENT INFORMATIONDate______/______/______
Legal Name______
(Last) (First) (Middle)(Preferred Name)
Date of Birth______/______/______Age______Sex M F Marital Status: S M D W
Phone Home (____)______Cell (____)______SSN______-______-______
Address______City______ST______Zip______
Employer______Phone ( ____)______
(if self employed name and type of business
Name of school if student______Full time Part time
Referred by______
Circle One: Doctor Hospital Relative Friend Attorney Coach Advertisement Other
IN CASE OF AN EMERGENCY, I GIVE PERMISSION TO NOTIFY:
Name______Relationship______
Home phone(______)______Other phone (_____)______
Insurance Information: Please give information about the holder of insurance
Primary:Secondary:
Insurance Company______Insurance Company______
Insured Name______Insured Name______
Relationship to patient______Relationship to patient______
SSN______DOB______SSN______DOB______
Policy or ID No.______Policy or ID No.______
Group No.______Group No.______
Employer______Employer______
If you have a Medicare replacement plan (i.e. Secure Horizons, Generations, etc.) please check here YES
Please give insurance cards and photo ID to the receptionist for copying.
Authorization: My signature indicates that I have read the above and grant authorization of treatment and am responsible for payment of fees and acknowledge that I have been provided access to the SOS HIPPA Privacy Notice and a copy thereof has been made available to me. I also authorize the release of medical information requested by my insurance carrier and authorize payment of medical benefits to the physician and Southwest Orthopaedic & Reconstructive Specialists.
X______
Page 1Signature of patient, parent, or legal guardian/ Relationship required
Patient Name______DOB_____/_____/_____Date______
Where/what are your current problems?______
Were your injured? YesNoExplain______
Work related accident? YesNoExplain______
Auto Accident? YesNoExplain______
Are you represented by an attorney? YesNoExplain______
Date your symptoms/problems began?______Current severity on a scale of 1-10?______
Were you treated at another hospital or by another physican? YES NO
If Yes by whom and when?______
Have you had X-RAYS MRI CT ULTRASOUND OR OTHER for this problem? (circle which)
If yes When and Where?______
Did you have surgery for this problem? YESNO
Date and Type______
MEDICATIONS AND DOSAGES (INCLUDE OVER- THE -COUNTER MEDICINES AND INHALERS)
Medication DosageFrequentlyMedication DosageFrequently
______
______
______
ALLERGIES REACTION ALLERGIES REACTION
Antibiotics Yes No______
Adhesive tape Yes No______Aspirin Yes No______
IVP Dye Yes No______Latex Yes No______
Others: ______
SOCIAL HISTORY
Occupation:______
Activities:______
Smoke YES NO If yes,______pack(s) daily for ______year(s). Quit smoking in ______
DrinkYES NO If yes,______beer, alcoholic drinks, glasses of wine per day month or year? (Circle one)
Have you ever been addicted to or dependent on drugs or pain medication?YES NO
Are you on a special diet? YES NO If yes, type:______
Height______Weight:______If female, are you pregnant? YES
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Patient Name______DOB_____/_____/_____Date______
ANESTHESIA HISTORY:
Date of last anesthetic: ______/______/______
Have you ever had an adverse reaction/ problem with anesthesia? YES NO
If yes, explain:______
Have you had blood relatives with anesthesia problem?YES NO
If yes, explain:______
SURGERIES/DATES;
Appendectomy YES NO Date______Cardiac bypass YES NO Date______
Cataracts YES NO Date______
Gallbladder YES NO Date______
Hernia YES NO Date______
Tonsillectomy YES NO Date______
Hysterectomy (female only) YES NO Date______
Fracture repair of______YES NO Date______
Hip replacement right left YES NO Date______
Knee cartilage right left YES NO Date______
Knee ligament right left YES NO Date______
Knee replacement right left YES NO Date______
Shoulder right left YES NO Date______
Other______Date______
Other______Date______
Other______Date______
DO YOU HAVE:
GENERAL
Cancer of______ YES NODiabetes-insulin dependent YES NO
Diabetes-diet or medication controlled YES NOThyroid disease YES NO
Fever YES NONight sweats YES NO
Rapid weight loss or gain YES NOFatigue YES NO
Anxiety/panic attacks YES NODepression YES NO
Jaundice YES NOHepatitis YES NO
Swollen ankles YES NOHigh blood pressure YES NO
EYES/EARS/HEAD:
Glaucoma YES NOCataracts YES NO
Blindness YES NOContacts YES NO
Partial plate YES NODentures YES NO
Hearing loss YES NOHearing aids YES NO
Migraine headaches YES NOOther______ YES NO
HEART:
Heart attack YES NOChest pain/angina YES NO
Heart failure YES NOHeart murmur YES NO
Palpitations YES NORheumatic fever YES NO
Pacemaker YES NOOther______ YES NO
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Patient Name______DOB_____/_____/_____Date______
Lungs:
Asthma YES NORecurrent bronchitis YES NO
Emphysema YES NOCOPD YES NO
TB YES NOOther______ YES NO
BREAST:
Lump YES NOBiopsy YES NO
Fibrocystic disease YES NOMastectomy YES NO
Other______ YES NO
ABDOMEN:
Heartburn YES NOHiatal hernia YES NO
GERD YES NOFrequent nausea/vomiting YES NO
Inguinal hernia YES NOLiver cirrhosis YES NO
Peptic ulcer disease YES NOOther______ YES NO
URINARY TRACT:
Recurrent bladder/kidney infections YES NORecent infection YES NO
Bladder control problems YES NOProstate disease YES NO
Kidney stones YES NOKidney failure YES NO
Dialysis YES NOKidney transplant YES NO
BONE/JOINTS:
Rheumatoid arthritis YES NOOsteoarthritis YES NO
Osteoporosis YES NOGout YES NO
Back Pain YES NOJoint pains YES NO
Muscle Cramps YES NOFractures YES NO
Other______ YES NO
NEUROLOGICAL:
Stroke YES NOParalysis YES NO
Numbness or tingling YES NOWeakness of arms or legs YES NO
Palpitations YES NOEpilepsy YES NO
Heart attack YES NOBlack out spells YES NO
Heart failure YES NOHead injury YES NO
Palpitations YES NOOther______ YES NO
BLOOD/VESSELS;
Easy bruising YES NOExcessive bleeding YES NO
Taking blood thinners YES NOAnemia YES NO
Blood clots YES NOPhlebitis YES NO
PVD YES NOSickle cell trait or disease YES NO
AIDS YES NOHIV YES NO
Blood transfusuins YES NOOther______ YES NO
FAMILY HISTORY (INDICATE FAMILY MEMBER IF YES):
Bleeding tendency______ YES NOHeart disease______ YES NO
Blood clots______ YES NOHigh blood pressure______ YES NO
Cancer______ YES NOOsteoarthritis______ YES NO
Depression______ YES NORheumatoid arthritis______ YES NO
Diabetes______ YES NOStroke______ YES NO
Heart attack______ YES NOTuberculosis______ YES NO
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