SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
*Please have paperwork completed by your appointment time and bring diagnostic films to review*
Patient Name: ____________Date: ______/______/______
Address:______City______State____Zip______
Sex: ¨Female¨Male Marital Status: ¨Single ¨Married ¨Widowed ¨Divorced
Social Security #:______Date of Birth: ______/______/______
Phone #’s: Home: (____)______Work: (____)______Cell: (____)______
Occupation (if student please indicate):______
Employer:______Address:______
Nearest Relative in Case of Emergency______
(Name) (Phone) (Relationship)
Insurance Information
(Please complete guarantor information if parent or spouse is responsible for patient.)
Insurance Company (Primary):______
Group #:______Policy #:______
Insurance Company (Secondary):______
Group #:______Policy #:______
Guarantor Name:______Social Security Number:______
Phone #’s: Home: (____)______Work: (____)______Cell: (____)______
Occupation: ______Insured Date of Birth: ______/______/______
Employer:______Address:______
Workers Compensation
Did this result from an accident at work? ¨Yes ¨No Date of Injury:______/______/______
If yes, give the employer’s name and where injury occurred:______
If you have an Attorney their name:______
Claim Number: ______Workers Comp Ins Co:______
24-Hour Cancellation Notice is Required,
Otherwise You Will Receive a No Show Charge of $50.00
Release of Benefits and Information
I authorize my insurance benefits to be paid directly to the doctor. I am financially responsible for any balance due. I authorize the doctor or insurance company to release any information required for this claim.
Signed (X): ______Date:______/______/______
I authorize and give consent to Dr. Hollis to evaluate and treat, which may include x-rays.
Signed (X): ______Date:______/______/______
Non-covered Services: I understand that most insurance contracts DO NOT COVER DME PRODUCTS AND SUPPLIES AND INJECTIONS, I AGREE TO ACCEPT RESPONSIBILITY FOR THESE CHARGES SHOULD THEY OCCUR.
Signed (X): ______Date:______/______/______
I acknowledge that I have received a copy of Sound Orthopaedics & Foot and Ankle Center, P.A. Notice of Privacy Practices with the effective Date of April 14, 2003 and have a full understanding of the contents.
Signed (X): ______Date:______/______/______
I acknowledge that it is my responsibility to pay al balances on my account within 30 days of notice. If for any reason I do not pay this, and the account is turned over to collections, I will be responsible for collection fees that may be added to my delinquent account.
Signed (X): ______Date:______/______/______
SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
Patient Name______Age:______
Referring Physician / Person:______
Primary Care Physician:______
Who else have you seen for this problem?______
CHIEF COMPLAINT:
Please state your main problem:______
Please describe your problem in detail:______
Date of onset:______How long have your symptoms been present?______
INJURY AND ACCIDENT INFORMATION:
Please describe the mechanism of injury:______
On the job injury (please describe): ______
Are you still working? ¨Yes ¨No Do you like your job? ¨Yes ¨No
Have you missed work ¨Yes ¨No If Yes, how much time?______Last date worked____/____/____
Have your symptoms changed since your initial injury ¨Yes ¨No If Yes, Describe:______
Motor Vehicle Accident (please describe):______
HISTORY OF PRESENT ILLNESS:
Which foot/ ankle is bothering you the most: ¨Right ¨Left
How severe is the problem? ¨Mild ¨Moderate ¨Severe ¨Disabling
How bad is your pain (please circle)?
No Pain 1 2 3 4 5 6 7 8 9 Worst Pain
Mark the area on your body where you feel the described sensations.
Numbness ///// Burning XXXXX Stabbing OOOOO Pins & Needles ------
FRONT INSIDE OUTSIDE
TOP BACK SOLES
Physician/PA______Date______
SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.f
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
HISTORY OF PRESENT ILLNESS (CONT):
Describe your pain (burn, ache, sharp, etc)______
How often do you have pain? (intermittent, constant)______
When does the pain occur (first step, night, weight bearing, at rest)?______
What makes it better? ______What makes it worse?______
Do you have swelling? ¨Yes ¨No Did you have swelling within 2 hours of injury ¨Yes ¨No
Do you have locking (cannot change foot position)? ¨Yes ¨No Describe:______
Do you have weakness/giving way? ¨Yes ¨No If Yes, Describe______
Do you have instability / history of sprains? ¨Yes ¨No If Yes, How Often______
Do you have catching or popping sensations? ¨Yes ¨No If Yes, Describe:______
Do you have numbness / tingling? ¨Yes ¨No If Yes, Describe______
Have you had prior injury / problems with this foot/ankle? ¨Yes ¨No If Yes, Describe______
TREATMENT INFORMATION:
What prior treatments have you had (i.e. physical therapist, chiropractor, massage therapist, etc)?
Please list and describe.
Treatment Name of Prescribing Doctor Location Date Improved/Unchanged
1. ______
2. ______
3. ______
4. ______
Have you had any diagnostic tests? ¨Yes ¨No If so please list:
Name of Prescribing Doctor Location of test Date of test Results
MRI______
Bone Scan______
Electrical Studies______
EMG/NCV______
X-Rays______
CT Scan______
Other______
Physician/PA______Date______
SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
REVIEW OF SYSTEMS:
Please describe any problems with head, eyes, ears, throat (i.e. sore throat, headache)
______
Please describe any problems with your gastrointestinal system:(i.e. nausea, vomiting, diarrhea)
______
Please describe any problems with your musculoskeletal & neurologic system (i.e. weakness, numbness)
______
Please describe any problems with your genitourinary system (i.e. urinary / fecal incontinence)
______
Please describe any problems with your pulmonary system (i.e. cough, shortness of breath)
______
Please describe any problems with your cardiovascular (i.e. palpitations, chest pain)
______
PAST MEDICAL HISTORY: Please list all medical problems.
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¨ Anemia
¨ AIDS/HIV/STD
¨ Asthma/COPD
¨ Arthritis
¨ Bleeding Problems
¨ Diabetes
¨ High Blood Pressure
¨ Heart Disease
¨ Skin Disease
¨ Hepatitis
¨ High Cholesterol
¨ Osteoporosis
¨ Parkinson’s
¨ Seizure Disorder
¨ Stroke
¨ Thyroid Disease
¨ Tumor (benign)
¨ Tumor (malignant)
¨ Ulcers
¨ None of the above
¨ Other
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Please list details or comments regarding above checked disorders:
______
PAST SURGICAL HISTORY: Please list all previous operations and hospitalizations.
TYPE YEAR REASON
1. ______
2. ______
3. ______
4. ______
FAMILY HISTORY: Please list any disorders in immediate family members.
1. ______
2. ______
SOCIAL HISTORY:
Do you exercise regularly? ¨Yes ¨No Type and amount per week______
Occupation:______Education / Last Grade Completed:______
Please check if applicable: ¨Married ¨Single ¨Divorced ¨Retired ¨Pregnant # of Children ______
Physician/PA______Date______
SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
MEDICATIONS: Please list all drugs including aspirin, laxatives, vitamins, herbs, and supplements.
DRUG NAME DOSE FREQUENCY
1. ______
2. ______
3. ______
4. ______
Do you smoke? ¨Yes ¨No Number of packs______How many years?______Quit When?______
Do you use tobacco? ¨Yes ¨No Number of tin______How many years?______Quit When?______
Do you drink alcohol? ¨Yes ¨No Type and number of drinks/week/month?______
Do you use drugs that are not medical? ¨Yes ¨No Type______
Are you taking any pain medications? ¨Yes ¨No Type______
ALLERGIES (including drug, latex, or other substance): ¨Yes ¨No
Please list drug name and reaction (i.e. rash, difficulty breathing, etc)
______
FOR OFFICE USE ONLY:
Weight ______Height ______Pulse ______SW5.07______
Girth Measurements: Calf Thigh Arm Forearm
L ______
R ______
I. Head/Neck II. Spine/ribs/pelvis III.RUE IV.LUE V.RLE VI.LLE Gait
Inspection/Palpation:
alignment symmetry crepitation effusion tenderness defects masses
Stability: laxity subluxation dislocation
Strength/tone: atrophy flaccid spasticity
Skin: induration erythema nodules rash lesions ulcers
Neuro: sensation touch pin vibration DTR/babinski
Lymphatic(2 areas): neck axillae groin other
Psychiatric: mental status orientation (time, place, person) mood/affect (depression, anxiety, agitation)
Cardiovascular: PVDZ swelling varicosities temp tenderness edema
Physician/PA______Date______
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