PATIENT MEDICAL HISTORY QUESTIONNAIRE
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):
How did you learn about our physicians?
Physician referral Community/Physician Seminar Friend/Relative Community Newsletter
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.
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:
Policy Number: Member:
Social Security Number:
Primary Care Physician:
Please Check Applicable Response
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
SYMPTOMS: First began:
Days Ago Weeks Ago
Started because of:
Motor Vehicle Accident
Days Ago Weeks Ago Months Ago Years Ago
PAIN: (check both intensity and duration)
SYMPTOMS WORSENED BY:
Walking Standing Sitting Stairs Lifting Carrying
SYMPTOMS IMPROVED BY:
Nothing Walking Rest Heat Ice
taken for symptoms?
LIMP: None Mild Moderate Moderate-Severe Severe
Cane (long walks)
PLEASE CHECK APPLICABLE RESPONSE
Holding on with 1 hand
Holding on with 2 hands
PHYSICAL THERAPY ATTENDED:
YOU HAVE HAD DONE: (please
check all that have been done for this problem)
you taken steroids during the last month?
Have you taken steroids at any time during your lifetime? Yes No
yes, please complete the following table.
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?
General Medications (FOR JOINT PROBLEMS) Please number as applies
Pain Medications (FOR JOINT PROBLEMS) Please number as applied
list all medications you are currently taking on a routine basis.
This would include blood thinners, insulin, aspirin, thyroid medicine,
MAJOR JOINT SURGERY
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:
GENERAL HEALTH: Excellent Good Fair Poor
HEAD Headaches History of Accidents
NECK Stiffness Pain Arthritis Thyroid Problem
SKIN Infections Boils Psoriasis
NOSE/THROAT Bleeding Hoarseness Polyps Sinus Problems Trouble Swallowing
Shortness of Breath
PLEASE CHECK ANY/ALL PROBLEMS ON THE FOLLOWING:
Metastasis (spread) to:
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 of hard liquor (like scotch, gin or vodka).
Never, I do not drink alcoholic beverages (If answered, skip to next
section on smoking)
history of drinking
history of drinking
How many drinks did you have on a typical day when you were/are drinking
(past or current)?
3. How often did you have 6 or more drinks on one occasion?
4. How long have you consumed alcoholic beverages? Years; or since (year).
What type of alcoholic beverage do you usually drink?
type of tobacco do you smoke?
How long have you smoked? years; or since (Year).
PLEASE LET US KNOW any information which you would like to convey to us that you feel is important that has not been covered in the above questionnaire:
MEDICAL RECORD RELEASE ON INFORMATION
I hereby authorize release of medical information to my insurance carriers and the following:
Referring Physician Name: