New Patient Registration Form

Today’s Date:

Account #:

First Name:

Middle Initial:

Last Name:

Mailing Address:

City:

State:

Zip:

Date of Birth:

Preferred Language:

Age:

E-Mail:

SSN:

Preferred Pharmacy:

Home Phone:

Cell Phone:

Marital Status:

Married Single Widowed Divorced

Sex:

Male Female

In case of Emergency, Notify:

Phone:

Relationship to patient:

Referred by:

Phone:

Insurance Information

Add new row

Employment Information

Employer:

Telephone:

Mailing Address:

City:

State:

Zip:

Responsible Party Information

Name:

SSN:

Date of Birth:

E-Mail:

Mailing Address:

City:

State:

Zip:

As the responsible party, I agree that all charges that are not directly paid by the insurance company will be my responsibility By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Responsible Party Signature:

Phone:

Payment of Benefits

I authorize payment of benefits, as determined by the insurance company, directly to the physician’s office. I understand that I still may be responsible for any amounts not paid by my insurance company. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature:

Date

Medical Release Authorization

I authorize any insurance company, organization, employer, hospital, physician, dentist, or pharmacist to release any information requested with regard to processing my claim. I certify that all information on this form is true and correct to the best of my knowledge. I know it is a crime to fill out this form with facts I know are false or to leave out facts I know are important. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature:

Date:

Cancellation of Scheduled Appointments

I understand that if I have a serious emergency and I am unable to come to my appointment, I will contact the office as soon as possible. In other cases, if I fail to cancel my appointment 24 business hours in advance, I will be charged $50.00 for the missed appointment. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Signature:

Date:

Patient History Form

Date of first appointment:

Time of appointment:

Last Name:

First Name:

Middle Initial:

Maiden Name:

Birthdate:

Birthplace:

Referred here by: (choose one)

Self Family Friend Doctor Other Health Professional

Name of person making referral:

The name of the physician providing your primary medical care:

Describe briefly your present symptoms:

Date symptoms began (approximate):

Diagnosis:

Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later):

Please list the names of other practitioners you have seen for this problem:

Add new row

Please list all the locations of your pain on your body over the past week.

Add new row

Rheumatologic (Arthritis) History

At any time have you or a blood relative had any of the following? (check if “yes”)

Arthritis (unknown type):

Yourself

Relative Name/Relationship

Lupus or “SLE”:

Yourself

Relative Name/Relationship

Osteoarthritis:

Yourself

Relative Name/Relationship

Rheumatoid Arthritis:

Yourself

Relative Name/Relationship

Gout:

Yourself

Relative Name/Relationship

Ankylosing Spondylitis:

Yourself

Relative Name/Relationship

Childhood Arthritis:

Yourself

Relative Name/Relationship

Osteoporosis:

Yourself

Relative Name/Relationship

Other arthritis conditions:

Patient’s Name:

Date:

Physician Initials:

Systems Review

As you review the following list, please check any problems, which have significantly affected you:

Date of last mammogram:

Date of last eye exam:

Date of last chest x-ray:

Date of last Tuberculosis Test:

Date of last bone densitometry:

Musculoskeletal

Morning stiffness

Joint pain

Muscle weakness

Muscle tenderness

Joint swelling

Allergic/Immunologic

Frequent sneezing

Increased susceptibility to infection

Endocrine

Excessive thirst

If you had checked joint swelling, please list all joints affected in the last 6 months:

For Women Only:

Age when periods began:

Periods regular?

Yes No

How many days apart?

Date of last period?

Date of last pap?

Bleeding after menopause?

Yes No

Number of pregnancies?

Number of miscarriages?

If you checked Weight Gain (Please Specify amount):

If you checked Weight Loss (Please Specify amount):

If you checked Morning stiffness, How long it lasts?

Minutes:

Hours:

If you checked Joint swelling, List joints affected in the last 6 mos.

Add new row

If you checked Transfusion, When?

Patient’s Name:

Date:

Physician Initials:

Social History

Do you drink caffeinated beverages?

Cups/glasses per day?

Do you smoke?

Yes No Past

If you chose Past, How long ago?

Do you drink alcohol?

Yes No

If you chose Yes, Number per week?

Has anyone ever told you to cut down on your drinking?

Yes No

Do you use drugs for reasons that are not medical?

Yes No

If yes, please list:

Do you exercise regularly?

Yes No

Type:

Amount per week:

How many hours of sleep do you get at night?

Do you get enough sleep at night?

Yes No

Do you wake up feeling rested?

Yes No

Past Medical History

Other significant illness (please list)

Natural or Alternative Therapies (chiropractic, magnets, massage, over-the-counter preparations, etc.)

Previous Surgeries

Add new row

Any previous fractures?

Yes

If Yes, Describe:

Any other serious injuries?

Yes

If Yes, Describe:

Family History

If Living

Father's Age:

Father's Health:

Mother's Age:

Mother's Health

If Deceased

Father's Age at Death:

Father's Cause of Death:

Mother's Age at Death:

Mother's Cause of Death:

Father Number of siblings:

Number living

Number decreased:

Mother Number of siblings:

Number living

Number decreased:

List ages of each:

Health of children

If you checked Cancer (Please specify your blood relation):

If you checked High blood pressure (Please specify your blood relation):

If you checked Asthma (Please specify your blood relation):

If you checked Leukemia (Please specify your blood relation):

If you checked Bleeding tendency (Please specify your blood relation):

If you checked Psoriasis (Please specify your blood relation):

If you checked Stroke (Please specify your blood relation):

If you checked Alcoholism (Please specify your blood relation)

If you checked Tuberculosis (Please specify your blood relation):

If you checked Colitis (Please specify your blood relation):

If you checked Rheumatic fever (Please specify your blood relation):

If you checked Diabetes (Please specify your blood relation):

If you checked Heart disease (Please specify your blood relation):

If you checked Epilepsy (Please specify your blood relation):

If you checked Goiter (Please specify your blood relation):

Patient’s Name:

Date:

Physician Initials:

Medications

Drug allergies:

Yes

If yes, please list:

Type of reaction:

PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.)

Add new row

PAST MEDICATIONS: Please review this list of “arthritis” medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Pain Relievers

Acetaminophen

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Codeine

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Propoxyphene

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Other:

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Other:

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Disease Modifying Antirheumatic Drugs (DMArDS)

Certolizumab

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Golimumab

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Hydroxychloroquine

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Penicillamine

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Methotrexate

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Azathioprine

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Sulfasalazine

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Quinacrine

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Cyclophosphamide

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Cyclosporine A

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Etanercept

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Infliximab

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Tocilizumab

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Other:

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Other:

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Osteoporosis Medications

Estrogen

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Alendronate

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Etidronate

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Raloxifene

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Fluoride

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Calcitonin injection or nasal

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Risedronate

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Other:

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Other:

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Gout Medications

Probenecid

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Colchicine

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Allopurinol

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Other:

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Other:

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Others

Tamoxifen

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Tiludronate

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Cortisone/Prednisone

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Hyaluronan

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Herbal or Nutritional Supplements

Length of time:

Please check: Helped?

A Lot

Some

Not At All

Reactions:

Please list supplements:

Have you participated in any clinical trials for new medications?

Yes

If yes, list:

Patient’s Name:

Date:

Physician Initials:

Activities of Daily Living

Do you have stairs to climb?

Yes

If yes, how many?

How many people in household?

Who does most of the housework?

Relationship and age of each

Who does most of the shopping?

Who does most of the yard work?

On the scale below, check a number which best describes your situation; Most of the time, I function…

Very Poorly

Poorly

Well

Very Well

Because of health problems, do you have difficulty:

(Please check the appropriate response for each question.)

Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.)

Usually

Sometimes

Walking?

Usually

Sometimes

Climbing stairs?

Usually

Sometimes

Descending stairs?

Usually

Sometimes

Sitting down?

Usually

Sometimes

Getting up from chair?

Usually

Sometimes

Touching your feet while seated?

Usually

Sometimes

Reaching behind your back?

Usually

Sometimes

Reaching behind your head?

Usually

Sometimes

Dressing yourself?

Usually

Sometimes

Going to sleep?

Usually

Sometimes

Staying asleep due to pain?

Usually

Sometimes

Obtaining restful sleep?

Usually

Sometimes

Bathing?

Usually

Sometimes

Eating?

Usually

Sometimes

Working?

Usually

Sometimes

Getting along with family members?

Usually

Sometimes

In your sexual relationship?

Usually

Sometimes

Engaging in leisure time activities?

Usually

Sometimes

With morning stiffness

Usually

Sometimes

Do you use a cane, crutches, walker or wheelchair?

Usually

Sometimes

Do you use a cane, crutches, walker or wheelchair? (check one)

cane

crutches

walker

wheelchair

What is the hardest thing for you to do?

Are you receiving disability?

Yes No

Are you applying for disability?

Yes No

Do you have a medically related lawsuit pending?

Yes No

Patient’s Name:

Date:

Physician Initials:

How does your condition affect everyday activities?

Fill out this form to assess how your condition may be impacting your daily life, and share the answers with your doctor. He or she may find the information useful when evaluating your condition and discussing treatment options.

Health Assessment Questionnaire-Disability Index*

Patient's Name:

Date:

Please choose the response that best describes your usual abilities over the past week:

Dressing & Grooming - Are you able to :

Dress yourself, including shoelaces and buttons?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Shampoo your hair?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To D

Arising - Are you able to :

Stand up from a straight chair?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Get in and out of bed?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Eating - Are you able to :

Cut your meat?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Lift a full cup or glass to your mouth?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Open a new milk carton?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Walking - Are you able to :

Walk outdoors on flat ground?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Climb up five steps?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Note to physician: The following aids and categories correlate to the activities listed above. If an item below is selected, and its corresponding activity (listed above) has been scored a 1, it will change to a 2.

Please check any AIDS OR DEVICES that you usually use for any of these activities:

Cane

Walker

Crutches

Wheelchair

Devices used for dressing (button hook, zipper, long-handled shoehorn, etc)

Built-up or special utensils

Special or built-up chair

Other

If you checked Other (Specify:)

Please check any categories for which you usually need HELP FROM ANOTHER PERSON:

Dressing & Grooming

Arising

Eating

Walking

Hygiene - Are you able to:

Wash and dry your body?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Take a tub bath?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Get on and off the toilet?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Reach - Are you able to:

Reach and get down a 5-pound object:

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

(such as bag of sugar) from above your head?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Bend down to pick up clothing from the floor?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Grip - Are you able to:

Open car doors?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Open previously opened jars?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Turn faucets on and off?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Activities - Are you able to:

Run errands and shop?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Get in and out of a car?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Do chores such as vacuuming or yard work?

Without any Difficulty

With some Difficulty

With much Difficulty

Unable To Do

Note to physician: The following aids and categories correlate to the activities listed above(Hygiene through Activities). If an item below is selected, and its corresponding activity (listed above) has been scored a 1, it will change to a 2.

Please check any AIDS OR DEVICES that you usually use for any of these activities:

Raised toilet seat

Bathtub seat

Jar opener (for jars previously opened)

Bathtub bar

Long-handled appliances for reach

Long-handled appliances in bathroom

Other

If you checked Other (Please specify:)

Please check any categories for which you usually need HELP FROM ANOTHER PERSON:

Hygiene

Reach

Gripping and opening things

Errands and chores

We are also interested in learning whether or not you are affected by pain because of your illness. How much pain have you had because of your condition in the PAST WEEK?

Pain Score:

0 (No Pain) - 100 (Severe Pain)

Considering all the ways that your arthritis affects you, rate how you are doing.

Pain Score:

0 (Very Well) - 100 (Very Poor)

*The Health Assessment Questionnaire (HAQ) Disability Index was developed by James F. Fries, MD, and colleagues at Stanford University and measures disability with the use of aids and devices. It is scored on a scale of 0-3 units. A score of 0 indicates the lack of any measurable degree of disability, whereas a score of 3 means that a patient is unable to perform all activities.

This Section is For Physician Use Only

For each category (ie, "Dressing & Grooming"), enter the highest number chosen in each row (0,1,2. or 3).

Dressing & Grooming:

Hygiene:

Arising:

Reach:

Eating:

Grip:

Walking:

Activities:

Total:

÷ Number of answered groups:

Total HAQ Disability index Score:

Please list any other activities you were previously able to do, but now can't because of your condition. Ask your doctor if additional treatment options may be appropriate for your condition.

Have additional questions for your doctor? Jot them down and start a conversation.

Cancellation Policy/No Show Policy

For Doctor Appointments and Surgery

1. Cancellation/ No Show Policy for Appointment

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book. If an appointment is not cancelled at least 24 hours in advance you will be charged a fifty-dollar ($50) fee; this will not be covered by your insurance company.

2. Scheduled Appointments

We understand that delays can happen however we must try to keep the other patients and doctors on time. If a patient is 15 minutes past their scheduled time we may have to reschedule the appointment.

3. Cancellation/ No Show Policy for Surgery

Due to the large block of time needed for surgery, last minute cancellations can cause problems and added expenses for the office. If surgery is not cancelled at least 10 days in advance you will be charged a two hundred dollar ($200) fee; this is will not be covered by your insurance company.

4. Account balances

We will require that patients with self-pay balances do pay their account balances to zero (0) prior to receiving further services by our practice. Patients who have questions about their bills or who would like to discuss a payment plan option may call and ask to speak to a business office representative with whom they can review their account and concerns. Patients with balances over $100 must make payment arrangements prior to future appointments being made. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Print Name Patient:

Signature Patient/Guardian:

Date:

Patient Account #:

(Office Use Only)

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