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


CANCERType:

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 of hard liquor (like scotch, gin or vodka).

Never, I do not drink alcoholic beverages (If answered, skip to next section on smoking)
Not a drinker within the past month , 6 months ,
1 year , more than 1 year .

PAST history of drinking
monthly or less
2 to 4 times per month
2 to 3 times a week
4 to 5 times a week
6 or more times a week

CURRENT history of drinking
monthly or less
2 to 4 times per month
2 or 3 times a week
4 to 5 times a week
6 or more times a week

2. How many drinks did you have on a typical day when you were/are drinking (past or current)?
0 drinks
1 to 2 drinks
3 to 4 drinks
5 to 6 drinks
7 to 9 drinks
10 or more drinks

3. How often did you have 6 or more drinks on one occasion?
In the Past year
Prior to the past year
Never
Less than monthly
Monthly
Weekly
Daily or almost daily

4. How long have you consumed alcoholic beverages? Years; or since (year).

5. What type of alcoholic beverage do you usually drink?
Beer
Wine
Wine Cooler
Cocktail
Shot of hard liquor (like scotch, gin or vodka)


SMOKING HISTORY
I have never smoked
I used to smoke less than 1/2 , 1/2 , 1 , 1 1/2 , 2 ,
greater than 2 packs per day.
I have not smoked in 6 months , 1 year , 2 years , greater than 2 years .
I currently smoke less than 1/2 , 1/2 , 1 , 2 , greater than 2 packs per day.

What type of tobacco do you smoke?
Cigarettes
Cigars
Pipe

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:

Address:

Phone: Fax:

Date:

PATIENT'S SIGNATURE:

Address:

Phone: Fax:

E-Mail address: