SOUTH TEXAS BONE & JOINT
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1 SOUTH TEXAS BONE & JOINT NEW PATIENT INFORMATION (PLEASE PRINT) DATE: PATIENT S NAME DATE OF BIRTH AGE M/ F SOCIAL SECURITY # MAILING ADDRESS PERMANENT OR TEMPORARY CITY, STATE, ZIP CODE (AREA CODE) CELL PHONE# (AREA CODE) HOME PHONE # PATIENT S EMPLOYER OCCUPATION (INDICATE IF A STUDENT) HOW LONG EMPLOYED (AREA CODE) BUSINESS PH# EMPLOYER S STREET ADDRESS CITY AND STATE ZIP CODE # OF CHILDREN AND AGES SPOUSE S NAME SPOUSE S SOCIAL SECURITY # SPOUSE S DATE OF BIRTH SPOUSE S EMPLOYER OCCUPATION (INDICATE IF A STUDENT) HOW LONG EMPLOYED (AREA CODE) BUSINESS PH# EMPLOYER S STREET ADDRESS CITY AND STATE ZIP CODE RELATIVE OR FRIEND (CIRCLE) CITY AND STATE ZIP CODE (AREA CODE) HOME PHONE # RELATIVE OR FRIEND (CIRCLE) CITY AND STATE ZIP CODE (AREA CODE) HOME PHONE # PREFERRED PHARMACY NAME & LOCATION PLEASE READ: IT IS CUSTOMARY TO PAY FOR PROFESSIONAL SERVICES WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE. THE PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. COPIES OF YOUR FEE SLIP WILL BE PROVIDED TO YOU. THIS, WITH YOUR MONTHLY STATEMENT, MAY BE SUBMITTED TO YOUR INSURANCE COMPANY FOR REIMBURSEMENT. PRIMARY INSURANCE NAME OF INSURANCE COMPANY SECONDARY INSURANCE NAME OF INSURANCE COMPANY ADDRESS TO MAIL CLAIMS ADDRESS TO MAIL CLAIMS CITY AND STATE ZIP CODE (AREA CODE) BUSINESS PH# CITY AND STATE ZIP CODE (AREA CODE) BUSINESS PH# NAME OF INSURED SOCIAL SECURITY # NAME OF INSURED SOCIAL SECURITY # GROUP # GROUP # POLICY # POLICY # MEDICARE (PLEASE GIVE NUMBER) RAILROAD RETIREMENT (PLEASE GIVE NUMBER) MEDICAID CASE # EFFECTIVE DATE INDUSTRIAL ACCIDENT WERE YOU INJURED ON THE JOB? YES NO WAS AN AUTOMOBILE DATE OF INVOLVED? YES NO ACCIDENT DATE OF INJURY ATTORNEY CASE? YES NO INDUSTRIAL CLAIM NUMBER NAME OF ATTORNEY WERE X-RAYS TAKEN OF THIS PROBLEM? IF YES, WHERE WERE X-RAYS TAKEN? (HOSPITAL, ETC.) DATE X-RAYS TAKEN YES NO HAVE YOU OR ANY MEMBER OF YOUR IMMEDIATE FAMILY BEEN TREATED BY OUR PHYSICIAN (S) BEFORE? WHEN? YES NO REFERRED BY STREET ADDRESS, CITY, STATE AND ZIP CODE (AREA CODE) PHONE # INSURANCE AUTHORIZATION AND ASSIGNMENT (PLEASE READ AND SIGN) I HEREBY AUTHORIZE M.D.TO FURNISH INFORMATION TO INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENTS AND I HEREBY ASSIGN TO THE PHYSICIAN (S) ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO MYSELF OR MY DEPENDENTS. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE. SIGNATURE
2 South Texas Bone & Joint 601 Texan Trail, Suite 300 Corpus Christi, TX Phone: Fax: Justin Klimisch, MD Last Name First Name MI Date of Birth: Age: Sex: ( ) Male ( ) Female Height: Weight: Race: ( ) African-American ( ) Asian ( ) Caucasian ( ) Hispanic ( ) Other How did you hear about our office? Medical History/Family History: You Family Explain Heart Disease ( ) Yes ( ) No ( ) Yes ( ) No High Blood Pressure ( ) Yes ( ) No ( ) Yes ( ) No Diabetes ( ) Yes ( ) No ( ) Yes ( ) No Asthma/Emphysema ( ) Yes ( ) No ( ) Yes ( ) No Cancer ( ) Yes ( ) No ( ) Yes ( ) No Stroke ( ) Yes ( ) No ( ) Yes ( ) No Gout/Pseudogout ( ) Yes ( ) No ( ) Yes ( ) No Gallbladder disease ( ) Yes ( ) No ( ) Yes ( ) No Kidney Problems ( ) Yes ( ) No ( ) Yes ( ) No Seizure/Neurologic Problems ( ) Yes ( ) No ( ) Yes ( ) No Stomach ulcers ( ) Yes ( ) No ( ) Yes ( ) No Skin Problems ( ) Yes ( ) No ( ) Yes ( ) No Bleeding problems/dvt ( ) Yes ( ) No ( ) Yes ( ) No Non-healing wounds ( ) Yes ( ) No ( ) Yes ( ) No Psychiatric problems ( ) Yes ( ) No ( ) Yes ( ) No Ears/nose/mouth/throat problem ( ) Yes ( ) No ( ) Yes ( ) No Gum disease/tooth abscess ( ) Yes ( ) No ( ) Yes ( ) No Prostate gland disorder ( ) Yes ( ) No ( ) Yes ( ) No Other ( ) Yes ( ) No ( ) Yes ( ) No Hx of MRSA ( ) Yes ( ) No ( ) Yes ( ) No Please list ALL MEDICATIONS AND DOSAGES that you are currently taking: Do you have any history of complications from surgery or anesthesia? ( ) Yes ( ) No If yes, explain Do you have any allergies to medications? ( )Yes ( ) No If yes, explain Other allergies
3 Surgical History: Procedure Date Doctor & Hospital/Location Social History: Marital Status: ( ) Single ( ) Married ( ) Divorced ( ) Widowed Living Situation: ( ) Alone ( ) With others Current Occupation Home: ( ) Single Story ( ) 2 ( + ) Story Number of Children Number still at home Tobacco use: ( ) Yes ( ) No ( ) Former If yes, amount and type Alcohol use: ( ) Yes ( ) No If yes, amount and type Drugs: ( ) Never Type/Frequency Exercise: ( ) Never ( ) Rarely ( ) Weekly ( ) Daily Type: Primary care physician: Other specialists: Review of Systems: Do you now or have you had any problems related to the following systems in the last 3 months? Constitutional Symptoms: GI: Fever ( ) Yes ( ) No Abdominal pain ( ) Yes ( ) No Chills ( ) Yes ( ) No Loss of appetite ( ) Yes ( ) No Headache ( ) Yes ( ) No Change in Bowel Movements ( ) Yes ( ) No Eyes: Nausea/vomiting ( ) Yes ( ) No Blurred vision ( ) Yes ( ) No Frequent Diarrhea ( ) Yes ( ) No Double vision ( ) Yes ( ) No Blood in Stool ( ) Yes ( ) No Pain ( ) Yes ( ) No Trouble swallowing ( ) Yes ( ) No Respiratory: Heartburn ( ) Yes ( ) No Sleep Apnea ( ) Yes ( ) No Cardiovascular: Wheezing ( ) Yes ( ) No Chest pain ( ) Yes ( ) No Cough ( ) Yes ( ) No Swelling of hands/feet ( ) Yes ( ) No Short of breath ( ) Yes ( ) No Abnormal heartbeat ( ) Yes ( ) No TB ( ) Yes ( ) No Varicose veins ( ) Yes ( ) No Neurological: High blood pressure ( ) Yes ( ) No Tremors ( ) Yes ( ) No Skin: Dizzy spells ( ) Yes ( ) No Rash ( ) Yes ( ) No Numbness ( ) Yes ( ) No Boils ( ) Yes ( ) No Paralysis ( ) Yes ( ) No Itching ( ) Yes ( ) No Endocrine: ENT: Excessive thirst ( ) Yes ( ) No Hearing loss ( ) Yes ( ) No Too hot/cold ( ) Yes ( ) No Ear Infection ( ) Yes ( ) No Tired/Sluggish ( ) Yes ( ) No Freq. nose bleeds ( ) Yes ( ) No Weight Gain/Loss ( ) Yes ( ) No Bleeding gums ( ) Yes ( ) No Genitourinary: Sore throat ( ) Yes ( ) No Urine retention ( ) Yes ( ) No Hematologic: Painful urination ( ) Yes ( ) No Hepatitis ( ) Yes ( ) No Frequency of urination ( ) Yes ( ) No Anemia ( ) Yes ( ) No Kidney stones ( ) Yes ( ) No HIV ( ) Yes ( ) No Do you take coumadin? ( ) Yes ( ) No Psychologic: Are you generally satisfied with your life? ( ) Yes ( ) No Do you feel depressed? ( ) Yes ( ) No Anxiety disorder ( ) Yes ( ) No
4 DATE PATIENT S NAME DOB Bone Health Questionnaire 1. Have you noticed any loss in height in the last 12 months or progressive YES NO spinal curvature? 2. Have you ever been diagnosed with any of the following? YES NO (Please check ALL that apply.) Rheumatoid Arthritis Diabetes Lactose intolerance Osteoporosis Osteopenia Thyroid Disease (Hyperparathyroidism, Hyperthyroidism, or treatment with high doses of thyroid hormones) 3. Do you or a family member have/have had any of the following as an adult? YES NO (Please check ALL that apply.) Spinal Fracture Hip Fracture Family history of bone disease Recent or unexplained weight loss Any other fracture or broken bone related to an injury or fall 4. Have you taken any of the following medications longer than YES NO THREE months at any time in your life? (Please check ALL that apply.) Birth Control/Contraceptives or Hormonal Bisphosphonates such as Boniva, Therapy Antiseizure medication such as Dilantan, Depakote, etc. Fosamax, Zometa, etc. Steroids such as Prednisone / Methylprednisolone, Glucosteroids, Glucocorticoids, etc. 5. If you are a FEMALE, are you pre or post-menopausal? YES NO 6. Have you had a bone density test (DXA)* in the last TWO years? YES NO *This test confirms the severity of bone loss and risk of fracture. PROVIDER USE ONLY: SCHEDULE REVIEWED-APPT NOT NEEDED
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7 TOTAL JOINT WORKSHEET PATIENT NAME DATE AFFECTED JOINT: RIGHT HIP LEFT HIP BOTH HIPS RIGHT KNEE LEFT KNEE BOTH KNEES WHICH BOTHERS YOU THE MOST (check only one): RIGHT HIP LEFT HIP RIGHT KNEE LEFT KNEE DO YOU USE A CANE /WALKER/CRUTCHES: YES NO HOW LONG HAS THE AFFECTED JOINT BEEN BOTHERING YOU: WHAT MAKES THE PAIN BETTER: WHAT MAKES THE PAIN WORSE: HOW FAR CAN YOU WALK WITHOUT PAIN: NONE HOUSE BOUND < 1 BLOCK <5 BLOCKS 5-10 BLOCKS UNLIMITED HOW MANY STEPS CAN YOU CLIMB: NONE 1-3 STEPS HAVE TO USE RAIL UNLIMITED DO YOU EXPERIENCE STIFFNESS OR LIMITED ROM IN THE AFFECTED JOINT: YES NO HAVE YOU HAD PHYSICAL THERAPY FOR THE AFFECTED JOINT: NO YES, IF SO WHEN: HAVE YOU TRIED ANTI-INFLAMMATORIES SUCH AS TYLENOL, ADVIL, IBUPROFEN: YES NO IF YES PLEASE LIST NAMES OF THOSE YOU HAVE TRIED: HAVE YOU TRIED PAIN MEDICATIONS SUCH AS HYDROCODONE, ULTRAM: YES NO IF YES PLEASE LIST NAME S OF THOSE YOU HAVE TRIED: HAVE YOU HAD THERAPEUTIC INJECTIONS SUCH AS STEROID OR VISCOSUPPLEMENT (EUFLEXXA, SYNVISC) DATES: DID THE INJECTION (S) HELP? YES NO HAVE YOU TRIED WEIGHT LOSS TO HELP DECREASE THE PAIN: YES NO HOW HAS YOUR PAIN LIMITED YOUR ACTIVITIES:
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