New Patient Forms Samimi Ortho

Patient Information

Date

SS/HlC/Patient ID #

Patient Name

Last Name

Middle Initial

Address

CIty

State

Zip

Email address

Sex

Male Female

Birthdate

Marital Status

Married Separated Widowed Divorced Single Minor

Partnered for?

Occupation

Patient Employer/School

Employer/School Address

Employer/School Phone

Spouse's Name

Birthdate

SS#

Spouse's Employer

Whom may we thank for referring you?

Insurance

Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Is patient covered by additional insurance?

Yes No

Subscriber's Name

Birthdate

SS#

Relationship to Patient

Insurance Co.

Group #

ASSIGNMENT AND RELEASE

I certify that I. and/or my dependent(s). have insurance coverage with

Name of Insurance Company

and assign directly to Dr.

all insurance benefits, if any. otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above·named doctor may use my health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year tram the date signed below.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient, Parent, Guardian of Personal Representative

Please print name at Patient, Parent, Guardian or Personal Representative

Date

Relationship to Patient

Phone Numbers

Home Phone

Cell Phone

Best time and place to reach you

INCASE OF EMERGENCY, CONTACT

Name

Relationship

Home Phone

Work Phone

Accident Information

Is condition due to an accident?

Yes No

Date

Type of accident

Auto Work Home Other

To whom have you made a report of your accident?

Auto Insurance Employer Worker Comp Other

Attorney Name (if applicable)

Patient Condition

Reason for Visit

When did your symptoms appear?

Is this condition getting progressively worse?

Yes No Unknown

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)

Other

How often do you have this pain?

Is it constant or does it come and go?

Does it interfere with your

Work

Sleep

Daily Routine

Recreation

Activities or movements that are painful to perform

Sitting

Standing

Walking

Bending

Lying Down

Health History

What treatment have you already received for your condition?

Medications

Surgery

Physical Therapy

Chiropractic Services

None

Other

Name and address of other doctor(s) who have treated you for your condition

Date of Last:

Physical Exam

Spinal Exam

Denial X-Ray

Spinal X-Ray

Chest X-Ray

MRI CT-Scan. Bone Scan

Blood Test

Urine Test

Place a mark on ' Yes" or "No' to indicate if you have had any of the following:

AIDS/HIV

Yes No

Alcoholism

Yes No

Allergy Shots

Yes No

Anemia

Yes No

Anorexia

Yes No

Appendicitis

Yes No

Arthritis

Yes No

Asthma

Yes No

Bleeding Disorders

Yes No

Bleeding

Yes No

Bronchitis

Yes No

Bronchitis

Yes No

Cancer

Yes No

Cancer

Yes No

Chemical Dependency

Yes No

Chicken Pox

Yes No

Diabetes

Yes No

Emphysema

Yes No

Emphysema

Yes No

Fractures

Yes No

Glaucoma

Yes No

Goiter

Yes No

Gonorrhea

Yes No

Gout

Yes No

Heart Disease

Yes No

Hepatitis

Yes No

Hernia

Yes No

Herniated Disk

Yes No

Herpes

Yes No

High Cholesterol

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Measles

Yes No

Migraine Headaches

Yes No

Miscarriage

Yes No

Mononucleosis

Yes No

Multiple Sclerosis

Yes No

Mumps

Yes No

Osteoporosis

Yes No

Pacemaker

Yes No

Parkinson's Parkinson's

Yes No

Pinched Nerve

Yes No

Pneumonia

Yes No

Polio

Yes No

Prostate Problem

Yes No

Prosthesis

Yes No

Psychiatric Care

Yes No

Rheumatoid Arthritis

Yes No

Rheumatic Fever

Yes No

Scarlet Fever

Yes No

Stroke

Yes No

Suicide Attempt

Yes No

Thyroid Problems

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors, Growths

Yes No

Typhoid Fever

Yes No

Ulcers

Yes No

Vaginal Infections

Yes No

Venereal Disease

Yes No

Whooping Cough

Yes No

Other

EXERCISE

None Moderate Daily Heavy

WORK ACTIVITY

Sitting Standing Light Labor Heavy labor

HABITS

Smoking

Packs/Day

Alcohol

Drinks/Week

Coffee/Caffeine Drinks

Cups/Day

High Stress level

Reason

Are you pregnant?

Yes No

Due Date

Injuries/Surgeries you have had

Falls

Date

Head Injuries

Date

Broken Bones

Date

Dislocations

Date

Surgeries

Date

Medications

Allergies

Vitamins/Herbs/Minerals

Add new Medication

Pharmacy Name

Pharmacy Phone

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