Workers Compensation Demographic

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Workers Compensation Demographic 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 Work Comp Information Insurance Address Phone Adjuster Fax Claim # Employer: Address Phone Contact Person Personal Demographic 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 How Did You Hear About Us? o Physician o Family/Friend o VO Website o Internet Search o Advertisement o Review Website o Social Media o Other Specifically, who or what was the source? 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 I. Did another doctor send you to this office for evaluation? o Yes o No If yes, who referred you: II. Problem involves the: o o o Bilateral o Shoulder o Elbow o Forearm o Wrist o Hand o Finger o Neck o Hip o Thigh o Knee o Leg o Ankle o Foot o Toe o Back III. Was there an injury which you believe directly resulted in your symptoms? o Yes o No (If no, skip to IV.) Date of injury: Is the injury work related? o Yes Is this the result of a motor vehicle accident? o Yes IV. Please give an approximate time (date, month, or year) when the symptoms began: V. Describe the injury and/or development of your problem: VI. 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 Brace/Splint o Crutches o Cast o Therapy o Chiropractic What medication was given? o Narcotic (Vicodin, Codeine, etc.) o Anti-inflammatory medication (Advil, Motrin, etc.) o Muscle relaxers (Flexeril, Soma, etc.) o Corticosteroids (Medrol Dosepak, etc.) o Injection VII. For the problem you are being seen for today, have you had any of the following: o X-rays o CT/CAT Scan o MRI o Nerve Test o Arthrogram o Myelogram o Discogram Have you had surgery on this body part? o Yes o No Have you had symptoms or an injury to this area before? o Yes o No If yes, please describe: VIII. Are you experiencing pain at the present time? o Yes o No Pain is described as: o Improved o Worse o The Same o Mild o Moderate o Severe o Sharp o Dull o Burning o Aching o Constant o Present only at times or with certain activities Does the pain radiate? o Yes o No If yes, where on your body? Is there: o Swelling o Numbness o Tingling o Weakness o A Mass o Deformity What makes your problem worse? What makes your problem better?

Medical History o Osteoporosis o Cancer o High Blood Pressure o Heart Disease o Diabetes o Paralysis o Arthritis o Ulcers o Poor Circulation o Asthma 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 Review of Systems: Are you experiencing any of these issues now? General Fever o Yes o No Night Sweats/Chills o Yes o No Night Pain o Yes o No Weight Loss o Yes o No Eyes Cataracts o Yes o No Blindness o Yes o No Double Vision o Yes o No HEENT Cough o Yes o No Sinus Problems o Yes o No Sore Throat o Yes o No Hearing Loss o Yes o No Dentures o Yes o No Loose Tooth 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 Wheezing o Yes o No Shortness of Breath o Yes o No Pain with Breathing o Yes o No Sputum Production o Yes o No Abdominal Heartburn o Yes o No Difficult Swallowing o Yes o No Nausea & Vomiting o Yes o No Urinary Incontinence o Yes o No Kidney Stones o Yes o No Musculoskeletal Joint Swelling o Yes o No Muscle Cramps o Yes o No Stiffness o Yes o No Skin & Breast Rash o Yes o No Changes in Moles o Yes o No

Review of Systems: Are you experiencing any of these issues now? (continued) Neurologic Seizures o Yes o No Loss of Consciousness o Yes o No Balance Problems o Yes o No Headaches o Yes o No Psychiatric Depression o Yes o No Hyperactivity o Yes o No Difficulty Sleeping o Yes o No Metabolism Weight Gain o Yes o No High Blood Sugar o Yes o No Blood Anemia o Yes o No Prolonged Bleeding o Yes o No Allergies Are you allergic to any medications? o Yes o No Please List: Are you allergic to food or environmental substances? o Yes o No Please List: Medications (Please list name of medication and dosage) Hospitalizations (Please list all hospitalizations you have had) Surgeries (Please list all surgeries type and year) FRONT BACK Pain Diagram Using the figures to the right, mark the areas where you feel the described sensation on your body. Use the appropriate symbols (indicated below) and include all affected areas. Ache +++++++++ +++++++++ Numbness ========= ========= Pins & Needles oooooooo oooooooo Burning ^^^^^^^^ ^^^^^^^^ Stabbing /////////////////// /////////////////// 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 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 Your feedback matters! Please help us improve the patient experience by filling out a short survey that will be sent via text message or email. Your contact information will not be used for any other reason, including junk or spam mail. o Yes, I would love to help. o No, I do not wish to participate. For Office Use Only: o Signed form received by: VOM 6814 03/2018

Request for Special Privacy Protections Ventura Orthopedics Medical Group, Inc. www.venturaortho.com Administrator 805-641-6415 As required by the Health Insurance Portability and Accountability Act of 1996, you have a right to request that we restrict our uses and disclosures of your protected health information with respect to treatment, payment and health care operations. You also have a right to request that we restrict our uses and disclosures of your health information with respect to disclosures to members of your family and other relatives or close personal friends or other person you identity who are involved in your care or payment for your care, or to notify or assist in notifying those individuals of your location, general condition or death. This medical practice does not have to agree to your request, but if we do, we will abide by our agreement until either of us terminates the agreement. I hereby request special privacy protection for Print Patient s Name Patient s Date of Birth You MAY speak/disclose my Health Information to: You MAY NOT speak/disclose my Health Information to: This is a complete list of all restrictions requested. All previous restriction requests are obsolete. Signature: Print Date: Phone: If not signed by the patient (or plan member), please indicate your relationship: o Parent or guardian of minor patient o Guardian or conservator of an incompetent patient o Beneficiary or personal representative of deceased patient o Other (specify) NOTE: By law, this restriction will not apply with respect to information necessary to provide emergency treatment, for uses or disclosures required by law, or for certain public health activities, judicial and administrative proceedings, law enforcement purposes, coroner investigations, organ or tissue donations, research activities, specialized government functions or workers compensation activities. VOM 6838 3/2017

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