New Patient Instructions Schneck Orthopedics & Sports Medicine welcomes you to our practice. In order to simplify your check‐
in process during your first appointment, please print and complete the following information. ALL SECTIONS MUST BE COMPLETED. Please bring your photo identification and insurance cards along with this packet to the reception window upon your arrival. Plan to arrive about 15 minutes prior to your scheduled time to allow your information to be entered into our electronic medical record system. As a reminder, Schneck Orthopedics & Sports Medicine is located on the fifth floor of Schneck. Close parking is available just off Brown Street. Enter through the revolving Patient Entrance door and take the elevators to the fifth floor. Our office is at the end of the hallway. This packet includes: 1. Patient Information: Please fill out every section. 2. Medical Information: To help us understand your current condition, please fill out every section. 3. Pain Management Agreement: Review and sign stating you have read and understand the terms of the agreement. Please ask questions if you do not understand the terms of the agreement. One copy will be retained in your medical record and you will keep one copy for your personal records. 4. Missed Appointment: Review and sign stating you have read and understand the terms of the agreement. Please ask questions if you do not understand the terms of the agreement. One copy will be retained in your medical record and you will keep one copy for your personal records. 5. Patient Contract: Review and sign stating you have read and understand the terms of the agreement. Please ask questions if you do not understand the terms of the agreement. One copy will be retained in your medical record and you will keep one copy for your personal records. Thank you for choosing Schneck Orthopedics & Sports Medicine for your healthcare needs. We look forward to seeing you!
411 West Tipton Street | Seymour, IN 47274 | 812.524.3311 | 877.333.7627 | www.SchneckOrtho.com
PATIENT INFORMATION SHEET
Patient Name:
Date of Birth:
Address:
City:
Marital Status:
Sex:
St:
Zip:
Home Ph.#:
Soc. Sec.#:
Do we have your permission to leave information related, but not limited,
to appointment, billing, negative test results on answering machine/
Home
Cell
Work?
No
voicemail at (please check box):
Work Ph. #:
Place of Employment:
Cell Ph.#:
Email Address:
Worker’s Comp?
Yes
No
RACE: (Please Check appropriate boxes)
AMERICAN INDIAN / ALASKA NATIVE
ASIAN
OTHER PACIFIC ISLANDER
CAUCASIAN
Preferred Language: (please check box))
HISPANIC / LATIN AMERICAN
Date of Injury: __________
AFRICAN AMERICAN
MORE THAN ONE RACE
NON-HISPANIC / LATIN AMERICAN
Responsible Party (if other than patient):
REFUSED TO REPORT
Sex:
Address:
Date of Birth:
City:
Soc. Sec.#:
NATIVE HAWAIIAN
REFUSED TO REPORT
St:
Home Ph.#:
Zip:
Cell Ph. #:
Work Ph.#:
Emergency Contact Name: (Outside the household) :
Home Ph.#:
Cell Ph.#:
Relationship:
HEALTH INSURANCE INFORMATION
PRIMARY INSURANCE
SECONDARY INSURANCE
Carrier Name:
Carrier Name:
Subscriber Name:
Subscriber Name:
Date of Birth:
Soc. Sec.#:
Date of Birth:
Soc. Sec.#:
*Insurance cards, photo ID and co-payments must be
*Insurance cards, photo ID and co-payments must be
presented at time of service.
presented at time of service.
INFORMED CONSENT REGARDING MY MEDICAL CONDITION
I authorize Schneck Orthopedics &
Sports Medicine to speak with the
individual(s) listed below regarding my
medical condition.
I authorize Schneck Orthopedics to
release any prescriptions, correspondence,
or medication samples, in a sealed
envelope, to the individual(s) listed below.
Name:
Name:
Relationship:
Relationship:
I only want medical information given to
me personally.
GENERAL CONSENT FOR CARE: I acknowledge that I choose to enter into care at Schneck Orthopedics & Sports Medicine, and hereby give
my consent for such care. I understand that I may be asked for additional consent for specific procedures and/or tests.
AUTHORIZATION & ASSIGNMENT: Please read and sign the following statement:
We will use and disclose your personal health information to treat you, to receive payment for the care we provide, and for other health care operations. Health care
operations generally include those activities we perform to improve the quality of care. We have prepared a detailed NOTICE OF PRIVACY PRACTICES to help you
better understand our policies in regards to your personal health information. The terms of the notice may change with time and we will always post the current notice at
our facilities and have copies available for distribution. I acknowledge that I have received a copy of the NOTICE OF PRIVACY PRACTICES.
I authorize Schneck Orthopedics & Sports Medicine to furnish information to other physicians, insurance carriers and other related entities concerning the illness or
medical treatment of my dependent or myself. I recognize and accept responsibility for payment of all medical fees regardless of any insurance I may have to assist me in
this responsibility. I also hereby assign to the provider(s) all insurance payments for medical services rendered to my dependent or myself, except those services for which
I have already paid prior to the filing of the insurance claim on my behalf. If for any reason the account should become delinquent, I agree to pay for all court costs,
collection and legal fees, and interest due.
I have read the above information.
Signature of Patient or Responsible Party
Date
Medical History Patient Name: ______________________________ Employer: _______________________ Phone #: _________________ Reason You Are Being Seen Today: ___________________________________________ Onset Date: __________________ Height: ________ Weight: ________ Pain Level Today 1 – 10 (with 10 being the worst): _______ Medications (or provide list): _____________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ History of Present Illness Day of Injury or Onset of Pain: _______________ Activity at Time of Injury: ___________________________________ Pain Duration:  Minutes  Hours  Days  Constant  Intermittent  Aching  Burning  Dull  Sharp  Stabbing  Spasm  Other Pain Quality: Pain Radiation:  None  Head  Shoulders  Arms  Legs  Other  Other Symptoms Exacerbated by:  Standing  Sitting  Bending  Lifting  Lying Down  Other ___________________________ Symptoms Improved by:  Standing  Sitting  Other __________________ Mechanism of Injury:  Sports‐related  Trauma‐related  Work‐related  None  Cold Therapy  Heat Therapy  Physical Therapy Current Therapy:  Degenerative Disk Dis. Pertinent Past History:  Neck Trauma  Back Injury  Head Trauma  Recent Surgery  Arthritis  Osteoporosis  Diabetes Mellitus  Infection  Cancer  Genetic Syndrome  Peripheral Vascular Dis.  Fractures  Aneurysm  Autoimmune Disease  Psychiatric Disorders Past Medical History (Please X if you have these or have a history of a certain condition.) List Allergies & Reactions (rash, itching, etc.): ________________________________________________________________ _____________________________________________________________________________________________________ Have you ever tested positive to MRSA?  Yes  No Past Medical History (Continued)  Diabetes  Hypothyroidism Endocrine:  COPD  Sleep Apnea  Shortness of Breath Respiratory:  Asthma Cardiovascular:  Atrial Fibrillation  Coronary Artery Disease  Heart Failure  Hypertension  GERD Gastro: Genitourinary:  Kidney Stones Musculoskeletal:  Fibromyalgia  Myocardial Infarction  Chest Pain  Peptic Ulcer Disease  Males: Benign Prostate Hyperplasia  Rheumatoid Arthritis  Fractures (list) __________________________  Arthritis  Osteoporosis  Brain Oncology:  Anemia  Blood  Breast  Colorectal  Endocrine  GI  Leukemia  Liver  Lung  Lymphoma  Prostate  Skin  Stomach  Thyroid  Other __________________________  Amputations (list) ______________________________ Neurologic:  Dementia  Multiple Sclerosis  Parkinson Disease  Restless Leg Syndrome Psychiatric: Tobacco Use: Alcohol Use: Substance Use:  Seizures  Strokes  Aneurysm  Migraines  Sciatica  Painkillers  Injection Drugs  Other _________________________________________  Anxiety  Bipolar Disorder  Depression  Drug Abuse  Suicidal Ideation  Non‐smoker  Smoker: ____ Packs per Day  None  0 – 2 per Day  2+ per Day  None  Amphetamines  Tranquilizers/Sedatives  Opiates Past Surgical History Endocrine:  Parathyroidectomy  Thyroid Surgery  Coronary Stent Cardiovascular:  Angioplasty  Other _______________________________  Heart Transplant  Pacemaker  Valve Replacement  Other ________________________________ Gastrointestinal:  Appendectomy  Colectomy  Gastric Bypass  Hernia Repair Musculoskeletal:  Knee Replacement (R or L | Year _______)  Hip Replacement (R or L | Year ________)  AKS (R or L | Year ______)  Spinal Surgery  Other ______________________ PAIN MANAGEMENT AGREEMENT Welcome to Schneck Orthopedics & Sports Medicine! Thank you for trusting us to be a partner in your healthcare. At Schneck, we will be sensitive to your needs and quickly and efficiently provide you with the best possible care. We will work in close partnership with you to help improve your quality of life, physical function, comfort, and independence. The purpose of this Agreement is to prevent misunderstandings about certain medicines you will be taking for pain management. This is to help both you and the physician comply with the law regarding controlled medications. This agreement relates to my use of controlled substance for pain management prescribed by a physician at Schneck Orthopedics & Sports Medicine. I have been informed and understand the policies regarding the use of controlled substances that are followed at Schneck Orthopedics & Sports Medicine. I understand I will be provided controlled substances only if I adhere to the following conditions: 1. All medications are to be taken as prescribed. If you take the medication in excess of what is prescribed and run out of the medication prior to the refill date, the refill will not be authorized early. 2. If you are being treated by a pain management physician, all medications must be managed by your existing pain management specialist. 3. Without advance written authorization from the doctor, a patient who has not been examined within the preceding 90 days or placed on a PRN status will not be given refills of medications. 4. Surgical patients will be given narcotic medication for an appropriate time following surgery as determined by the surgeon. If pain medications are required after this period, you will be referred to your primary care physician, or a pain management specialist for continued management. 5. Prescriptions for medications with the potential for misuse, abuse, and addiction are carefully monitored through Indiana’s INSPECT program. Requests for refills of these medications will be evaluated on a case‐by‐
case basis. If you lie or are otherwise dishonest about your use of these medications, you will be dismissed from the practice and the proper authorities will be notified. 6. For patient safety, this office requires you to get your pain medications from one medical doctor only. 7. It is your responsibility to safeguard your prescriptions and narcotic medications. Lost or stolen prescriptions or medications will not be replaced. 8. All pain medications that you are allergic to or unable to tolerate must be brought back to the office for destruction before an alternate will be prescribed. 9. Alteration of any written prescription, or sharing, trading, or selling your medication is a federal offense and will be reported. 10. Refill requests may be made during regular office hours. For refills that can be called in, have the pharmacy fax a request to our office. Refill requests received after 3:00 pm will be filled the following day. Refills will not be made after hours, on weekends, or holidays, ______________________________________ Patient or Guardian Signature ____________________ Date MISSED APPOINTMENT POLICY The following is our office policy regarding failure/missed appointments: 1. First Failure – Verbal warning 2. Second Failure – Charged for visit 3. Third Failure – Dismissal from practice Please sign below to acknowledge you have read and understand the above policy. ______________________________________________ _______________________ Patient Signature Date NOTE: If you are more than 15 minutes late for an appointment, you will have to reschedule. PATIENT CONTRACT As a patient of Schneck Orthopedics & Sports Medicine, it is our objective to provide you with the high quality, effective, medically necessary health care treatment you deserve. The doctors, nurses, and staff of Schneck Orthopedics & Sports Medicine are committed to treat you with respect in an environment of care that is healthy and safe for you and all of our patients, nurses, physicians, and other staff. In order for us to meet our objective and honor our commitments to you, you must cooperate with your physicians, nurses, and staff and not disrupt the environment of care. If you fail to cooperate with your treatment or diagnostic tests, disrupt the environment of care, or threaten or intimidate the nurses, physicians, staff, or other patients, we cannot deliver the care that you and our other patients require. If your continued behavior prevents us from delivering the care you need, threatens staff or other patients or creates an unsafe environment, you will be discharged as a patient of Schneck Orthopedics & Sports Medicine. This Patient Contract indicates that you acknowledge that the following behaviors are prohibited and unacceptable conduct at this location. I [patient name] _____________________________________understand and agree: 1. I will take my medications as prescribed and will refrain from ingesting any recreational, illegal, or prescription drugs not administered by Schneck Orthopedics & Sports Medicine. 2. I will cooperate with my treatment, therapies, and diagnostic procedures, which includes being in my room at the time diagnostic test and/or procedures are to be performed. 3. I will not curse, shout or threaten any staff member of Schneck Orthopedics & Sports Medicine. 4. I will be held responsible if my spouse or anyone on my behalf curses, shouts, or threatens any staff member of Schneck Orthopedics & Sports Medicine. 5. I will follow the financial and appointment policies. I understand that continued incidents as described above are disruptive to a patient and physician relationship. The consequences for not fulfilling this contract include notification to my physicians and may result in my immediate dismissal from Schneck Orthopedics & Sports Medicine. A copy of this contract will be included in my medical record. Patient Signature: _______________________________ Date:_____________ Time:__________ Witness Signature: ______________________________ Date:____________ Time:___________