Patient Information

Last Name:	*	First Name:	*	Date of Birth:	*
Sex:	MaleFemale *	Marital Status:	Select Single Married Widow Divorced *	Social Security:
Home Address:	*	Floor/Apt/Suite:
City:	*	State:	*	Zip:	*
Home Phone:	*	Cell:		Race:
Employer:		Work Phone:	*
Employer Address:		Floor/Suite:
City:		State:		Zip:
Referred by:		Primary Care Dr:	*	Phone:	*
Address:		Address2:		E-Mail Address:
City:		State:		Zip:

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Injury Information

Is injury condition related to:	Select Work School Auto Accident None *	Date of Accident:
Part of Body Injured:		Do you have an attorney for this injury? YesNo
If Yes Do you authorize this office to submit medical and billing information to your attorney:			YesNo
Name of attorney:		Phone:
Address:		Address2:
City:		State:		Zip:

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Medical Insurance Information

Primary Insurance

INSURANCE CO:	*	POLICY HOLDER'S NAME:	*
Policy Holder's SS:	*	Policy Holders Relationship to Patient:	Select Self Spouse Parent Other *
Policy Holder's Date of Birth:	*	Employer:	*
INS.CO Address:		Floor/Suite:
City:		State:		Zip:
Phone:		ID:	*	Group/Policy:	*
Referral Required:	YesNo *

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Secondary Insurance

INSURANCE CO:		POLICY HOLDER'S NAME:
Policy Holder's SS:		Policy Holders Relationship to Patient:	Select Self Spouse Parent Other
Policy Holder's Date of Birth:		Employer:
INS.CO Address:		Floor/Suite:
City:		State:		Zip:
Phone:		ID:		Group/Policy:
Referral Required:	YesNo

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Patient Name: *		Date: *
Please answer the following questions- Do you have:
Fever/Chills?	YesNO	Sensitivity to heat?	YesNO
Unexplained Weight Loss?	YesNO	Sensitivity to cold?	YesNO
Recent Weight Loss?	YesNO	Skin rash?	YesNO
Glasses/contact lenses?	YesNO	Open Sores?	YesNO
Hearing Loss?	YesNO	Headaches?	YesNO
Oxygen Dependence?	YesNO	Dizziness?	YesNO
Sleep apnea?	YesNO	Anxiety?	YesNO
Shortness of breath?	YesNO	Depression?	YesNO
Easy bruising/bleeding?	YesNO	Environmental allergies?	YesNO
GI Bleed/Black Stool?	YesNO
Please list the medications you are currently taking.

Medication Name	Strength	Condition(i.e high blood pressure,diabetes,thyroid problems,etc.)
*

Please list any allergies below.

Emergency Contact:		Relationship:
Emergency Contact Phone Number:		Pharmacy Name:
Pharmacy Address:		Pharmacy Address2:
City:		State:		Zip:
Telephone Number:

Smoke:	YesNO	Frequency:		Packs Per day:	Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Occasionally:		How Many:	Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Alcholic Beverages:	YesNO	Frequency:		Occasionally:

Please list all past general surgeries:
SURGERY	DATE	DOCTOR
*	*	*

List any Orthopaedic Surgeries:	DATE	DOCTOR
*	*	*

I CONSENT TO MEDICAL TREATMENT BY FRANK FEMINO MD,STEPHEN DUCEY MD,SETH QUELER MD,AND I HEREBY AUTHORIZE FEMINO-DUCEY-QUELER ORTHOPAEDIC GROUP TO FURNISH INFORMATION TO INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENT. I HEREBY ASSIGN TO FEMINO-DUCEY-QUELER ORTHOPAEDIC GROUP ALL PAYMENT FOR MEDICAL AND OR SURGICAL SERVICES RENDERED TO MYSELF OR MY DEPENDENTS.I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE. I AGREE TO PAY ALL COSTS OF COLLECTION,INCLUDING A REASONABLE ATTORNEY'S FEES.SHOULD THIS ACCOUNT BE PLACED WITH AN ATTORNEY FOR COLLECTION.

INITIAL: *

DATE: *

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