Patient Name: Date of Birth: Sex: M F. Patient's SSN: Home Phone: Pediatrician: Home Address: City, State, Zip:

Size: px

Start display at page:

Download "Patient Name: Date of Birth: Sex: M F. Patient's SSN: Home Phone: Pediatrician: Home Address: City, State, Zip:"

Job Rogers
5 years ago
Views:

PATIENT INFORMATION Patient Name: Date of Birth: Sex: M F Patient's SSN: Home Phone: Pediatrician: Home Address: City, State, Zip: How was your child referred to our office?

1 PATIENT INFORMATION Patient Name: Date of Birth: Sex: M F Patient's SSN: Home Phone: Pediatrician: Home Address: City, State, Zip: How was your child referred to our office?: Emergency Room Pediatrician Friend Television Who has legal custody of patient?: Mother Father Guardian Other, please list relation PARENT/GUARDIAN INFORMATION Mother's Name: Date of Birth: SSN: Mailing Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: address: Father's Name: Date of Birth: SSN: Mailing Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: address: EMERGENCY CONTACT Name: Relationship to Patient: Home Phone: Work Phone: Cell Phone: Is this person authorized to bring patient for medical treatment? Yes No Who else is authorized to bring patient for medical treatment? Primary Insurance : Phone: INSURANCE INFORMATION Mailing Address: City, State, Zip: Policy Holder's Name: Date of Birth: SSN: Patient's Policy Number: Is this injury the result of a motor vehicle accident? YES NO Secondary Insurance : Phone: Mailing Address: City, State, Zip: Policy Holder's Name: Date of Birth: SSN: Patient's Policy Number: I understand that payment of all medical care is due at the time of service. The parent and/or legal guardian who signs this form is responsible for any and all co-pays, deductibles, co-insurance, and/or unpaid balances not covered by insurance, regardless of marital status. I further authorize all medical and/or surgical benefits be paid directly to Pediatric Orthopedics of SW Florida for any medical care rendered to my dependant. I hereby authorize Pediatric Orthopedics of SW Florida to release any medical information necessary to process medical claims. Signature: Date:

2 The purpose of Meaningful Use is to improve patient care by providing practitioners with access to accurate and complete information about their patients. For the patient, this means improved care and greater ability to make informed decisions about their health care. Please complete the following information regarding the patient and return it to Check-In Patient name Patient DOB / / Language q English q Spanish Only q Other Gender q Female q Male Race q Caucasian q African American q Latino/Hispanic q Other Ethnicity q Latino/Hispanic q Not Reported q Other Do you wish to have access to your records through a patient portal on our website? q Yes q No

3 growing bones expert care peace of mind INJURY QUESTIONNAIRE Pediatric Orthopedics of Southwest Florida requires all patients to provide the following information before your initial treatment. Patient Name: Insured Name: DOB: ID#: Injury Auto Accident Other Accident Date of Injury: Where did injury occur?: How did the accident occur? Do you believe another party is responsible for causing the injury or accident? Yes No For motor vehicle accidents, please provide the following: Insurance Company Name & Address: Adjuster s Name & Contact Number: Policy Number: Claim Number: Parent/Legal Guardian Signature: Date: created 2/11/15

4 Pediatric O rtholjedics ofswfl is finnly committed to full comljliance widt uuvs and regu llltiojl," relating 10 l)atienls rights. PRIVACY NOTICE This notice describes how medical information about you may be used and disclosed and how you can access this Information. Please review it carefully. Prr.w/ Of1iter T~ ledhl)fle' (2391 ~ PetlltriC Ort"...I OfSWfl IS!21 HotJ/elnCOurt fon ~' ~'ti S ~l r905 (2 391~ 32 S 100 f z. 1239) 43U629 Pediatric DrtfrOI lcs OfSWIL

5 (,PHIlO UiHj Hf :P'H1'f i1p~w 1" tj gh, i f i~f!-~.~ IL il'i l' I df,!inl. ' ~ ~! 8' '.i ~~...f. _ P».~ Ii P~iH ill f n 'jih. :t- ~..,!! l "h ",it ~I~' '~! ' rpipp f!!i::;;~ j~f:ph :1 5' 10 Zi?,.' z ~ _ ~, [ 1 ii,ll!t}'h' =.. ~.i'lhi ' Jlp l '.LI. ~ Pi :ih '> -pph I «, d!i -a'5!l i 'II It"l ~~1 n! :! ; H!mll :,,; It! t ~ i~l~ 7!!. J.i.!!~ ~p hij~ d ll~'~ ' i~ II ilihl: tl. It '!" g,... ' J iu1j " I' ' d~a~h P'P! -. lh~, f,th:q i 8.]aQi ~g,.' 1~~. B J.LH -ii..~~",...,.,f "'< ~ llijih T H;q i,,1' '." 'i~ ';H'. ~ 8'1. r... lp lu HI~~ hlh.! t ' ll~qp i i. i Hn.i~ 1li,,., r ' nm [r j!.- ~!i i Tf l He ~ ~ i!oihq ff j i qq~~i'~ B g f 8'! 1 t, s " i,j ~..,~h~ Hill!l H j~!h ~ 'if HJ ;lftf~i! i ~fi:" 5 ;1 II n,gh l! I: 1-!,~ i' i I. 11 "f.1 ijh~. Ii; -I thii ii j H., 1!!!H ih!:liiih _ft ;"'! ~ 0 ' r L-t r If II. il '" I";q Ii Pi" " II ~ iiii ill i " ~! i h 'I it

6 growing bones expert care peace of mind Pediatric Orthopedics of SWFL PRIVACY PRACTICES ACKNOWLEDGEMENT ACKNOWLEDGEMENT FORM I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. Child Name Child Birthdate Parent Signature X Date

9 ORTHOPEDIC!HEALTH!HISTORY Today s Date: Name Date of Birth Is your child a new patient? Yes No if no, is this a new problem? No Yes Reason for Visit: Past Medical History: None Yes if so, please list child s prior and current illnesses and injuries Past Surgeries/Hospitalizations: None Yes if so, please provide procedures performed and dates Current Medications: None Yes if so, please list Any Allergies (Medications, Foods, Latex, etc.): No Yes if so, please list Family History (Parents/Siblings age and health status): Review of Systems (Please indicate if you child has a health problem in any of the following areas) No Yes System Circle Conditions (if present) Fill in for Other Conditions Eyes (Glaucoma, Glasses) Ears/Nose/Throat (Deafness, Otitis, Sinusitis) Heart (Murmur, Valve Defect) Lungs (Asthma, Bronchitis, Tuberculosis) Abdomen (Hepatitis, Colitis) Kidneys/Bladder (Reflux, Incontinence, Infections) Muscles/Bones (Fractures, Joint Problems) Skin (Rashes, Eczema, Unusual Birth Marks) Neurologic (Seizures, Headaches, Delay, Cerebral Palsy) Psychologic (ADHD, Depression) Endocrine (Diabetes, Thyroid Disease, Obesity) Hematologic (Anemia, Sickle Cell, Leukemia, Lymphoma) Infectious/Inflammatory(HIV, Recurrent Infections, Latex Allergy) Birth History Born On Time? Yes No if No, at how many weeks gestation was patient born? weeks What was the birth weight? Pounds Ounces Was patient born via C-Section? No Yes if Yes, why? Did baby present Breech? No Yes Were there any complications with the pregnancy/delivery? No Yes if Yes, why? Developmental History Age when first: Sat independently Hand your child writes with? Right Left Crawled [Girls: Age at first menstruation? ] Walked Does your child smoke? No Yes Talked Involved in sports? No Yes if so, please list What grade is your child in?

10 List of Current Medications Patient Name: Patient DOB: Today s Date: List all tablets, patches, drops, ointments, injections, etc. Include Prescription and over-the-counter medications, as well as vitamins and dietary supplements. Also list any medicine your child takes only on occasion such as albuterol, allergy medications, inhales, etc. Medication Dose How is it taken? Reason for taking? Date Started Prescriber Name of pharmacy you use: Phone Number: 8/17/15

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address

Patient Information. Date of Birth Sex Marital Status / / Male Female Single Married Other. Address Patient Information Patient Information Date of Birth Sex Marital Status Male Female Single Married Other Social Security Number - - Why We Ask for Race and Ethnicity Patient Goes By: Email Address In