Neck & Spine Patient Demographic

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Neck & Spine Patient Demographic o New Patient o Return Patient o Update Account #: Physician: Last Name First Name MI: Address City State Zip Home Phone o OK to Leave Msg. Work Phone o OK to Leave Msg. Cell Phone o OK to Leave Msg. Email Do you prefer to receive reminder messages in the: o Morning o Afternoon o Evening Do you prefer: o Voice Message o Text Message o If you would like to make special arrangements regarding how we should contact you please see a staff member. Family Physician Referring Provider Address Address DOB Marital Status Sex: o M o F Social Security # Employer Address Emergency Contact Relationship Phone Insurance Information Primary Insurance Subscriber/Policy Holder Name Birth Date Relationship to Patient Social Security # Secondary Insurance Subscriber/Policy Holder Name Birth Date Relationship to Patient Social Security # ID # Group # ID # Group # If Patient is a Minor Student Status: o Full Time o Part Time Father s Name DOB Work Phone Mother s Name DOB Work Phone Injury Information Date of Onset Area of Pain Injury? o Yes o No If Yes, o Auto o Work o Other How Did Injury Occur Race: o Hispanic o White o Asian o African American o Native Hawaiian o Other o Refuse to Report Ethnicity: o Hispanic o Non-Hispanic o Other o Refuse to Report Preferred Language: o English o Spanish o Chinese o Japanese o Other Do you need an interpreter present during your examination? o Yes o No Each Patient (Or Responsible Party) is Financially Responsible for Services rendered. While we are pleased to assist in the preparation of Insurance Forms, the obligation for payment of our fees remains that of the patient. I hereby authorize payment to Ventura Orthopedics for Medical Services rendered. I authorize the release of any information required in the course of my examination or treatment. Responsible Party Name (Please Print) Signature of Responsible Party Date

OFFICE USE ONLY Patient Name Date Date of Birth Height Weight Vitals Referring Physician Primary Care Physician FRONT BACK On the diagram at left, mark the area where you feel pain or sensation. On the scale below, place an X next to your pain level (10 + worst pain) 0 5 10 How much of your total pain is: Neck or back pain % Arm or leg pain (including hip/buttocks) % Total 100 % I. Did another doctor send you to this office for evaluation? o Yes o No If yes, who referred you: II. Problem involves my: o Neck o Back Problem radiates to my: o o o Shoulder o Arm o Hand o Fingers o Hip o Thigh o Leg o Foot o Toes o Toes III. Was there an injury which resulted in your symptoms? o Yes o No Date of injury: Is the injury work related? o Yes o No If yes, type of work: IV. Please give an approximate time (date, month, or year) when the symptoms began: V. Have you sought medical treatment for this problem prior to this visit? o Yes o No If so, where: o Emergency Room o Urgent Care o Physician s Office o Other Name of care provider and/or facility who treated you: What treatment was given? o Physical Therapy o Injections What medication was given? o Narcotic (Vicodin, Codeine, etc.) o Muscle relaxers (Flexeril, Soma, etc.) o Anti-inflammatory medication (Advil, Motrin, etc.) o Steroids (Medrol Dosepak, etc.) VII. Have you had any studies of the involved area within the past year? o X-Rays o CT/CAT Scan o MRI o Myelogram o Discogram Have you had surgery on this body part? o Yes o No If yes, please describe: Have you had symptoms or an injury to this area before? o Yes o No If yes, please describe: Does the pain keep you up at night? o Yes o No How far can you walk (in miles or blocks)?

Medical History o High Blood Pressure o Diabetes o Heart Disease o Cancer o Other: Social History Tobacco Use: Are you a... o Current Smoker o Former Smoker o Never Smoked If a smoker, how long have you smoked? o <1 year o 1-10 years o 10+ years How many cigarette packs per day? o <1 pack o 1-2 packs o 3+ packs If you used cigarettes in the past, but no longer smoke, when did you quit smoking? Do you drink alcohol regularly? o Yes o No How many drinks per week? o <4 drinks o 5-9 drinks o 10+ drinks Have you used or do you use other drugs? o None o Street Drugs o Steroids o Other Level of education completed: o Elementary o High School o College o Graduate Marital Status: o Single o Married o Divorced o Widowed Occupation: Family History Mother o Alive o Deceased o Diabetes o High Blood Pressure o Heart Disease o Stroke o Unknown Father o Alive o Deceased o Diabetes o High Blood Pressure o Heart Disease o Stroke o Unknown Siblings o Alive o Deceased o Diabetes o High Blood Pressure o Heart Disease o Stroke o Unknown Pregnancy If you are a Female between the age of 10-65, are you pregnant? o Yes o No Allergies Are you allergic to any medications? o Yes o No Please List: Review of Systems: Are you experiencing any of these issues now? General Fever o Yes o No Night Sweats/Chills o Yes o No Eyes Cataracts o Yes o No Double Vision o Yes o No Head/Neck Sinusitis o Yes o No Sore Throat o Yes o No Heart Chest Pain o Yes o No Irregular Heart Beats o Yes o No High Blood Pressure o Yes o No Lungs Shortness of Breath o Yes o No Sputum Production o Yes o No Abdominal Heartburn o Yes o No Nausea & Vomiting o Yes o No Urinary Incontinence o Yes o No Skeletal Joint Swelling o Yes o No Joint Redness o Yes o No Muscle Cramps o Yes o No Stiffness o Yes o No Neurologic Seizures o Yes o No Balance Problems o Yes o No Headaches o Yes o No Mental Depression o Yes o No Anxious o Yes o No Fatigue o Yes o No Difficulty Sleeping o Yes o No Blood Prolonged Bleeding o Yes o No Anemia o Yes o No

Medications (Please list name of medication and dosage) Hospitalizations (Please list all hospitalizations you have had) Surgeries (Please list all surgeries type and year) Patient Signature Date Physician Signature Date

Acknowledgement of Receipt of Notice Ventura Orthopedics Medical Group, Inc. www.venturaortho.com Administrator 805-641-6415 Patient Name I hereby acknowledge that I received a copy of this medical practice s Notice of Privacy Practices. (please check one) o Yes o No I would like to receive a copy of any amended Notice of Privacy Practices by e-mail at: Signed: Date: Print Name: Telephone: If not signed by the patient, please indicate your relationship to the patient: o Parent or guardian of minor patient o Guardian or conservator of an incompetent patient o Beneficiary or personal representative of deceased patient Online Survey We want to hear from you in our online survey! We will not send you junk or spam mail, just one survey to ask how your experience with Ventura Orthopedics has been. You will receive an email from Press Ganey to fill out our survey. o Yes, please send me a survey. o No, I do not wish to participate in the survey. For Office Use Only: o Signed form received by: VOM 6814 03/2017

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