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NEW PATIENT MEDICAL HISTORY QUESTIONNAIRE

DATE: DOCTOR:
NAME: AGE:
SOCIAL SECURITY #:
HEIGHT: WEIGHT: SEX: MALE FEMALE
DATE OF BIRTH: RACE:
E-MAIL ADDRESS (IF AVAILABLE):
If healthcare information was made available on the internet, would you access it? Yes No

Emergency Contact (Someone NOT in your home):
Name: Phone:

How did you learn about our physicians?

Physician referral Community/Physician Seminar Friend/Relative Community Newsletter
Internet
Other:

Good Samaritan Hospital Manual Outpatient Medicare Questionnaire

Medicare requires that the following questions be asked and answered for each date of any inpatient or outpatient service rendered. Failure to answer these questions and provide accurate information may result in a denial by Medicare to pay for any claim. Read each question carefully and answer by checking a yes or no in the appropriate box.

Both patient and spouse retirement dates are required. Disability dates for those recipients under the age of 65 and other possible insurance carriers. Renal patients please provide the start date for dialysis and answer the information in question 11.

Worker's Compensation claims with Medicare as your Medicare carrier answer question 6 below and all Medicare questions. If an automobile accident provide date of accident and auto insurance carriers name and address and answer question 8 and all Medicare questions.

Managed Care Health Maintenance Organizations require preauthorization and referrals in most cases. This is your responsibility to obtain prior to having services rendered. Our staff will coordinate the verification and authorization with your physician. A managed care form signed is necessary for all managed care carriers.

Patient's Signature:

  1. Is the patient a member of a Health Maintenance Organization (HMO), or a Medical Health Maintenance Organiziation, exluding a Medicare Supplemental? Yes or No

If Yes, the name of your insurance, address, telephone number, member or policy number, social security number of member and the name and phone number of your primary physician.

Name of HMO: Phone:
Address:
Policy Number: Member:
Social Security Number:
Primary Care Physician:

  1. Is the patient a member of a hospice organization and is the illness related to the patient's terminal illness?
    Yes No
  2. Are you receiving black lung? Yes or No Date Benefits Began:
    Is illness covered by black lung? Yes No
  3. Are the services to be paid by a government program such as a research grant? Yes No
  4. Has the Department of Veteran's Affairs authorized and agreed to pay for services at this facility? Yes No
  5. Is the injury due to a worker-related accident/condition? Yes No
    Date of Injury: Insurance Company:
    Employer (where injury occurred):
    Address and Telephone Number for Insurance:

    Claim # and your social security number:
  6. Is injury due to non work-related injury? Yes No
    Date of Accident:
  7. Was the illness/injury caused by an automobile accident? Yes No
  8. Was another party responsible for this accident? Yes No
  9. Are you entitled to Medicare based on age: Yes No
    Retirement Date for Patient:
    Retirement Date for Spouse:
    Disability-Start Date:
    Is disability entitled to any member of your family employed? Yes No
    If yes, where?:
  10. End Stage Renal: Start Date:
Please Check Applicable Response
Knee
Hip
Ankle
Foot
Leg
Shoulder
Hand
Wrist
R L R L R L R L R L R L R L

R L
Other
LOCATION OF PAIN:
Knee All Over Inside Front Outside Along prior scar Back
Hip Groin Buttocks Inside of Thigh Front of Thigh Outside of Thigh
Ankle All Over Outside Inside Top Bottom
Foot All Over Outside Inside Top Bottom
Leg All Over Outside Inside Thigh Calf
Shoulder Outside Inside Front Back
Hand All Over Fingers Palm Back
Wrist All Over Outside Inside Top
SYMPTOMS: First began:
Days Ago Weeks Ago

Started because of:
Twisting Injury Fall/Sports Injury Fracture/Break Motor Vehicle Accident Contusion
Spontanously Other (describe):

Increased In:

Frequency
Intensity
Both

Days Ago Weeks Ago Months Ago Years Ago

PAIN: (check both intensity and duration)

On Weight-Bearing: None Slight Mild Moderate Severe Totally Disabling
Rarely Intermittently Continous

Rest Pain: None Slight Mild Moderate Severe Totally Disabling
Rarely Intermittently Continous

Night Pain: None Slight Mild Moderate Severe
Rarely Intermittently Continous

SYMPTOMS WORSENED BY:

Walking Standing Sitting Stairs Lifting Carrying

SYMPTOMS IMPROVED BY:

Nothing Walking Rest Heat Ice
Medications taken for symptoms? Yes No

LIMP: None Mild Moderate Moderate-Severe Severe

SUPPORT NEEDED: None 1 Crutch 2 Crutches Cane (long walks)
                           Cane Full Time 2 Canes Walker Unable to walk

PLEASE CHECK APPLICABLE RESPONSE
WALKING DISTANCE
With Support 
Without Support
Unlimited  Unlimited
More than 1 Mile More than 1 Mile
1/2 to 1 Mile 1/2 to 1 Mile 
1/4 to 1/2 Mile 1/4 to 1/2 Mile
1 Block 1 Block
Less than 1 Block Less than 1 Block
Indoors Only Indoors Only
Unable Unable

STAIR CLIMBING: Normal Holding on with 1 hand Holding on with 2 hands
        One step at a time Unable to climb stairs

PHYSICAL ACTIVITY LEVEL: Heavy Labor Active Moderately Active
       Sedentary Moderately Restricted Marked Restricted

BRACE: No Yes    Type:

PHYSICAL THERAPY ATTENDED:
No Yes HELPFUL NOT HELPFUL

TESTS YOU HAVE HAD DONE: (please check all that have been done for this problem)

X-rays Nerve Tests CT Scan Bone Scan   Blood Tests
MRI Arthrogram Fluid Analysis Diagnostic Arthroscopy EMB
Sonogram Mylogram Joint Fluid Withdrawals Injections  
Other:  

STEROID USE
Have you taken steroids during the last month? Yes No
                    If so, current does (mg/day)
                    Date of last dose
Have you taken steroids at any time during your lifetime? Yes No

If yes, please complete the following table.
Please use the following categories for duration: <1month; 1-2 months; 2-3 months; 3-6 months; or >6 months


MEDICATION
DOSE
(mg/day)
DURATION
     
     
     
  
Common Steroids
Cortisone Sterapred packs
Prednisone Cortisone acetate
Prednisolorie Decadron
Dexanethasone Hydrocortone
Corticosteroids Solumedrol
Prelone syrup Celestone
                 

Please answer the following questions.

If you do not know the answer, write in D.K. for don't know.
What is the highest dose of steroids you have ever taken?
How long did you take this dose?

Why were you prescribed steroids?

Nephrotic Syndrome Kidney Transplantation Other Kidney Disorder
Other Organ Transplantations Skin Disorder Collagen Disease
Herb Medication Brain or Spine Surgery Blood Disorder
Rheumatoid Arthritis Systemic Lupus Erythematosus Allergy
Asthma Other

MEDICATIONS:
General Medications (FOR JOINT PROBLEMS) Please number as applies

1 - Taking now, helps 2 - Taking now, not helping 3 - Took - no help
4 - Took, helped 5 - Took, unable to tolerate  
Aspirin Feldene
Plaquenil Indocin
Clinoril Trilisate
Gold Steroids
Butazalidin Nalfon
Tolectin Motrin
Prednisone Volteran
Meclomen Ansaid
Vioxx Celebrex
Other

Pain Medications (FOR JOINT PROBLEMS) Please number as applied
1 - Taking now, helps 2 - Taking now, not helping 3 - Took - no help
4 - Took, helped 5 - Took, unable to tolerate  

Aspirin Tylox (Percocet)
Darvon Dilaudid
Percodan Morphine
Tylenol Talwin
Codiene Demerol
Tylenol #3 Tylenol #4
Vicodan Lortab mg
Ultram  
Other

Please list all medications you are currently taking on a routine basis. This would include blood thinners, insulin, aspirin, thyroid medicine, etc.

VITAMINS/SUPPLEMENTS:
Please list all vitamins, minerals and supplements you take on a routine basis.

ACTIVITIES:
(Please indicate applicable response)
1 = Currently able to do 2 = Cannot currently do, but would like to be able to do
Carrying Lifting Stooping Stairs
Skiing Golf Tennis  
Other:

MAJOR JOINT SURGERY
Joint
Procedure
Helpful
Complications during or after surgery
       
       
       

BLOOD CLOTS:
Have you ever had blood clots (thrombophlebitis) in your leg veins? Yes No When?
Were you hospitalized? No Yes How Long?

How was diagnosis made? Doctor's Suspicion Dye x-ray into veins Scan
Ultrasound Doppler Other:
Treatment Given: Heparin Coumadin No Treatment Other

Joint Injections: No Yes     HELPFUL         NOT HELPFUL

If Yes, how many and how long have you been receiving them
Approximately how long since your last injection

OTHER ORTHOPEDISTS SEEN:
Physician's Name
Approximately how long ago did you last see them
Was surgery recommended
Type of surgery recommended
       
       
       
       

MEDICAL CONDITION
GENERAL HEALTH: Excellent Good Fair Poor
HEAD Headaches History of Accidents
NECK Stiffness Pain Arthritis Thyroid Problem
SKIN Infections Boils Psoriasis
EYES
Glasses
Cataract
Cataract Surgery
Pain
Legally Blind
Yes No
Right Left
Right Left
Right Left
Right Left
EARS
Hearing Loss
Hearing Aid
Ringing/Buzzing
Infection
Right Left
Right Left
Right Left
Right Left

NOSE/THROAT Bleeding Hoarseness Polyps Sinus Problems Trouble Swallowing
RESPIRATORY Asthma Wheezing Chronic Cough Shortness of Breath
Coughing up Blood Pain on Breathing

PLEASE CHECK ANY/ALL PROBLEMS ON THE FOLLOWING:
HEART
STOMACH/BOWEL
Chest Pain Ulcer
Heart Disease  Loss of Appetite
Leg Cramps - Night Swelling
Leg Cramps - Walking Constipation
Leg/Ankle Swelling Hemorrhoids
Irregular Heartbeat Colitis
Fast Heartbeat Nausea/Vomiting
High Blood Pressure Pain
Low Blood Pressure Change in Bowel Habits
Cold Fingers/Toes Gall Bladder Problems
Sweating Fingers/Toes Pancreatittis
Other Other
BLEEDING
METABOLIC
Anemia Diabetes
Hypoglycemia
Other   Other


URINARY
Leakage Strong Urine
Pain on Urination Back Pain
Sores on Genitalia Discharge/Drainage
Bloody Urine Frequent Urination
Trouble Starting Urination Night Time Urination
Trouble Stopping Urination Infections
Herpes AIDS
AIDS Related Complex

NEUROLOGICAL
 PSYCHOLOGICAL
Headaches Nervous Breakdown
Seizures (Epilepsy) Crying Frequently
Paralysis Tension
Fainting Feeling Blue
Stroke (R L) Anxious
Numbness  Stress Prone
Other Cannot Sleep
Exhaustion
  Other


PRIOR SURGERIES
Neck Fusion Gall Bladder Removal
Back Fusion Caesarian Section
Brain Surgery Appendectomy
Thyroid Surgery Prostate Removal
Heart Bypass Balloon Angioplasty
Bowel Removal Bladder Repair
Kidney Removal Hemorrhoidectomy
Hysterectomy Tubal Ligation
Kidney Stones Vascular Surgery
Lumbar Disc Removal Vein Ligation/Stripping
Cataract Removal Hernia Repair R L
Chest Surgery Stomach Removal
Colostomy Other:

HOSPITALIZATIONS
Please list any major hospitalizations and the age at which they occurred:

PRIOR DISEASE
ALLERGIES (list specifics)
Hepatitis Systemic Infection Pollen
Syphilis Local Infection Medicines
AIDS Joint Infection Foods
Herpes Other
CANCER
Type:
Primary Site:
Metastasis (spread) to:
FEMALE HISTORY
Menopause Number of Pregnancies
Regular Menstration Number of Live Births
Irregular Menstration

Birth Control Pills Currently In Past
IUD

ALCOHOL HISTORY
  1. How often did you have a drink containing alcohol in the past year? Consider a "drink" to be a can/bottle of beer, a glass of wine, a wine cooler, or one cocktail or a shot