New Patient Packet Form - Oklahoma Arthritis Center

Oklahoma Arthritis Center
1701 S. Renaissance Boulevard, Suite 110
Edmond, OK 73013
Phone: (405) 844-4978 Fax: (405) 844-0562
New Patient Information
Welcome to the Oklahoma Arthritis Center. Thank you for choosing us as partners in your healthcare. Our goal is
to provide you with the highest quality medical care available in a convenient setting.
To schedule your appointment, please read, complete, sign, and return the enclosed items:
1.
2.
3.
4.
5.
Patient Communication Form
Patient History Form
Health Assessment Questionnaire
Demographic Review Form
Front and Back Copy of Insurance Card(s)
Please return the completed forms listed above, prior to scheduling your appointment, by mail or fax as follows:


By mail - 1701 S Renaissance Blvd, Suite 110, Edmond, OK 73013
By fax - (405) 844-0562. Attention: “New Patient Coordinator”
Please arrive at our office 15 minutes prior to your scheduled appointment time.
On the day of your appointment, please bring:



Your current Insurance card(s)
Driver License or State Identification card
Any recent Lab work or X-Ray results.
If you are unable to keep your appointment, please contact our office and speak with a staff member two (2)
business days prior to your scheduled appointment.
Should you have any questions, please feel free to contact our New Patient Coordinator at (405) 844-4978,
extension 551.
We look forward to meeting you!
-The Staff at the Oklahoma Arthritis Center
Oklahoma Arthritis Center
1701 S. Renaissance Boulevard, Suite 110
Edmond, OK 73013
Phone: (405) 844-4978 Fax: (405) 844-0562
Helpful Information
Office Hours:
Mon. – Thurs. 8:00 a.m. to 4:00 p.m.
Friday
8:00 a.m. to 11:00 a.m.
For New Patient Appointment inquiries, call (405) 844-4978, extension 551. If you are unable to keep your
appointment, kindly call us at least two days before your scheduled appointment. We will work with you to
reschedule your appointment to a more convenient time.
If you have questions about your insurance, we will be happy to assist you. Specific coverage issues should be
directed to your insurance company’s member services department, typically located on the back of your insurance
card. Please keep in mind it is the patient’s responsibility to provide us with current insurance information and to
bring insurance card(s) to each visit.
In medical facilities we have many people with allergies and sensitivities, therefore, our clinic is a Fragrance Free
Environment. Please do not wear scents, perfumes or colognes on the day of your appointment.
For prescription refills, please call your pharmacy to request the refill. As an option, Arthritis Pharmacy Solutions
is located in our clinic for your convenience and can be reached at (405) 844-6955. The pharmacy will call our
prescription refill line for authorization to refill the prescription. We require at least 24 hours for the authorization
of the refill. Pain medications cannot be filled early.
Laboratory tests are a routine part of your healthcare. If your provider indicates that you will be contacted
regarding your results, please allow three (3) business days. In most cases, your lab results will be discussed at
your next scheduled appointment.
Phone messages are checked and returned frequently. If you would like to speak with a nurse or provider
regarding a medical question, please call us at (405) 844-4978. You may also leave a voice message on the
nurses’ line and we will get back to you within 24 hours.
In the event of an emergency, please go to your nearest emergency room.
After your first appointment, if you have an urgent medical need after regular hours of operation, a provider is
available to you. To reach the provider on-call, you may call Doctor’s Choice answering service at (405) 6315335 and they will contact the provider on call. A provider will return your call.
Oklahoma Arthritis Center
1701 S. Renaissance Boulevard, Suite 110
Edmond, OK 73013
Phone: (405) 844-4978 Fax: (405) 844-0562
Directions to Oklahoma Arthritis Center





Take Hwy 77 (Broadway Extension) to 15th
Street in Edmond
Turn West onto 15th Street
Go through Kelly Avenue
Take the very first left onto Renaissance
Blvd. (There is a large cement marquee at
the entrance that says “Renaissance” on it.)
We are the third building on the right with
white columns in the front.


OR:



Take I-35 to Edmond to 15th Street, Exit 140
Go West 4 miles on 15th Street to Kelly
Avenue
Go through Kelly Avenue
Take the very first left onto Renaissance
Blvd. (There is a large cement marquee at
the entrance that says “Renaissance” on it.)
We are the third building on the right with
white columns in the front.
PATIENT COMMUNICATION CONSENT FORM
Oklahoma Arthritis Center
Patient:
DOB:
MRN:
FollowMyHealth.com Patient Portal Consent
Oklahoma Arthritis Center is offering a Patient Portal site in partnership with “Follow My Health.” This is a secure web portal
that allows you, as a patient, to access and manage not only your medical records at Oklahoma Arthritis Center but with
other providers as well. Through the “Follow My Health” Patient Portal you will have access to your medication list, lab
results, problem list, scheduled appointments, etc as well as have the option to request appointments.
Please read the following carefully:
DO NOT USE THE PORTAL TO COMMUNICATE AN EMERGENCY
CALL 911 or Go to the Emergency Room
 We are offering the “Follow My Health” patient portal as a convenience to you at no cost. We do not sell or give away any
private information, including e-mail addresses. This is an optional service and we reserve the right to suspend or
terminate the patient portal at any time and for any reason.
 Your use of this Patient Portal is entirely voluntary and accessing the Patient Portal will not affect the current level or
quality of care you receive from Oklahoma Arthritis Center.
 You may view scheduled appointments and request appointments.
 You may view selected health information such as lab results, allergies, medications, current problems, etc.
 It is YOUR RESPONSIBILITY to notify “Follow My Heath” if there is a change in your e-mail account or if you password
has been compromised.
 By using this patient portal, you agree to protect your password from any unauthorized individuals. It is YOUR
RESPONSIBILITY to protect your Personal Health Information located on the portal.
 You agree to not hold Oklahoma Arthritis Center responsible for any network infractions beyond our control.
 Oklahoma Arthritis Center is in partnership with a third party, “Follow My Health,” to provide selected personal health
information to you. Oklahoma Arthritis Center does not have access to your Patient Portal other than to send information
to it that is contained in your medical record here. Oklahoma Arthritis Center does not have the ability to see your portal
information or maintain the portal.
 Yes, please sign me up for the portal.
If yes, email Address for Portal _______________________________________________________
Last 4-Digits of SSN _________ (this will be used as your security code for registration)
Signature:___________________________________________________ Date:___________________________
Patient History Form
Date of first appointment:
Time of appointment:
Birthplace:
Birthdate:
Name:
LAST
FIRST
MIDDLE INITIAL
MAIDEN
Age:
Address:
STREET
/
MONTH
/
DAY
YEAR
Sex: F M
APT#
CITY
MARITAL STATUS:
Never Married
Spouse/Significant Other:
Alive/Age
STATE
ZIP
Telephone: Home (
Work (
Married
Divorced
Separated
Deceased/Age
)
)
Widowed
Major Illnesses
EDUCATION (circle highest level attended):
Grade School
7
8
9
10 11 12
College
1
2
3
Occupation
Referred here by: (check one)
4
Graduate School
Number of hours worked/average per week
Self
Family
Friend
Doctor
Other Health Professional
Name of person making referral:
The name of the physician providing your primary medical care:
Do you have an orthopedic surgeon?
Yes
No If yes, Name:
Describe briefly your present symptoms:
Example:
Date symptoms began (approximate):
Please shade all the locations of your pain over the
past week on the body figures and hands.
Example
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:
Adapted from CLINHAQ, Wolfe F and Pincus T. Current Comment – Listening to the patient – A
practical guide to self report questionnaires in clinical care. Arthritis Rheum. 1999;42 (9):1797808. Used by permission.
RHEUMATOLOGIC (ARTHRITIS) HISTORY
At any time have you or a blood relative had any of the following? (check if “yes”)
Yourself
Relative
Yourself
Name/Relationship
Relative
Name/Relationship
Arthritis (unknown type)
Lupus or “SLE”
Osteoarthritis
Rheumatoid Arthritis
Gout
Ankylosing Spondylitis
Childhood arthritis
Osteoporosis
Other arthritis conditions:
Patient’s Name
Date
Patient History Form © 1999 American College of Rheumatology
SYSTEMS REVIEW
As you review the following list, please check any of those problems, which have significantly affected you.
Date of last mammogram
Date of last Tuberculosis Test
/
/
/
Date of last eye exam
/
/
/
Date of last bone densitometry
Date of last chest x–ray
/
/
/
/
Constitutional
Gastrointestinal
Integumentary (skin and/or breast)
Recent weight gain
amount
Recent weight loss
amount
Fatigue
Weakness
Fever
Eyes
Nausea
Vomiting of blood or coffee ground
material
Stomach pain relieved by food or milk
Jaundice
Increasing constipation
Persistent diarrhea
Blood in stools
Black stools
Heartburn
Genitourinary
Easy bruising
Redness
Rash
Hives
Sun sensitive (sun allergy)
Tightness
Nodules/bumps
Hair loss
Color changes of hands or feet in the
cold
Neurological System
Difficult urination
Pain or burning on urination
Blood in urine
Cloudy, “smoky” urine
Pus in urine
Discharge from penis/vagina
Getting up at night to pass urine
Vaginal dryness
Rash/ulcers
Sexual difficulties
Prostate trouble
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?
Musculoskeletal
Headaches
Dizziness
Fainting
Muscle spasm
Loss of consciousness
Sensitivity or pain of hands and/or feet
Memory loss
Night sweats
Psychiatric
Pain
Redness
Loss of vision
Double or blurred vision
Dryness
Feels like something in eye
Itching eyes
Ears–Nose–Mouth–Throat
Ringing in ears
Loss of hearing
Nosebleeds
Loss of smell
Dryness in nose
Runny nose
Sore tongue
Bleeding gums
Sores in mouth
Loss of taste
Dryness of mouth
Frequent sore throats
Hoarseness
Difficulty in swallowing
Cardiovascular
Pain in chest
Irregular heart beat
Sudden changes in heart beat
High blood pressure
Heart murmurs
Respiratory
Shortness of breath
Difficulty in breathing at night
Swollen legs or feet
Cough
Coughing of blood
Wheezing (asthma)
Patient’s Name
Morning stiffness
Lasting how long?
Minutes
Hours
Joint pain
Muscle weakness
Muscle tenderness
Joint swelling
List joints affected in the last 6 mos.
Excessive worries
Anxiety
Easily losing temper
Depression
Agitation
Difficulty falling asleep
Difficulty staying asleep
Endocrine
Excessive thirst
Hematologic/Lymphatic
Swollen glands
Tender glands
Anemia
Bleeding tendency
Transfusion/when
Allergic/Immunologic
Frequent sneezing
Increased susceptibility to infection
Date
Patient History Form © 1999 American College of Rheumatology
SOCIAL HISTORY
Do you drink caffeinated beverages?
PAST MEDICAL HISTORY
Do you now or have you ever had: (check if “yes”)
Cups/glasses per day?
Cancer
Heart problems
Asthma
Do you smoke? Yes No Past – How long ago?
Goiter
Leukemia
Stroke
Do you drink alcohol? Yes No Number per week
Cataracts
Diabetes
Epilepsy
Nervous breakdown
Stomach ulcers
Rheumatic fever
Bad headaches
Jaundice
Colitis
Kidney disease
Pneumonia
Psoriasis
Anemia
HIV/AIDS
High Blood Pressure
Emphysema
Glaucoma
Tuberculosis
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:
Other significant illness (please list)
Do you exercise regularly? Yes No
Type
Natural or Alternative Therapies (chiropractic, magnets, massage,
over-the-counter preparations, etc.)
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
___________________________________________________________
_____________________________________________________
_____________________________________________________
Previous Operations
Type
Year
Reason
1.
2.
3.
4.
5.
6.
7.
Any previous fractures? No Yes Describe:
Any other serious injuries? No Yes Describe:
FAMILY HISTORY:
IF DECEASED
IF LIVING
Age
Health
Age at Death
Cause
Father
Mother
Number of siblings
Number living
Number deceased
Number of children
Number living
Number deceased
List ages of each
Health of children:
Do you know of any blood relative who has or had: (check and give relationship)
Cancer
Heart disease
Rheumatic fever
Tuberculosis
Leukemia
High blood pressure
Epilepsy
Diabetes
Stroke
Bleeding tendency
Asthma
Goiter
Colitis
Alcoholism
Psoriasis
Patient’s Name
Date
Patient History Form © 1999 American College of Rheumatology
MEDICATIONS
Drug allergies:
No
Yes
To what?
Type of reaction:
PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.)
Name of Drug
Dose (include
strength & number of
pills per day)
How long have
you taken this
medication
Please check: Helped?
A Lot
Some
Not At All
1.

10.

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.
Drug names/Dosage
Length of
time
Reactions
Please check: Helped?
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
A Lot
Some

Not At All

Circle any you have taken in the past
Ansaid (flurbiprofen)
Arthrotec (diclofenac + misoprostil)
Daypro (oxaprozin)
Disalcid (salsalate)
Meclomen (meclofenamate)
Tolectin (tolmetin)
Aspirin (including coated aspirin)
Dolobid (diflunisal)
Motrin/Rufen (ibuprofen)
Feldene (piroxicam)
Nalfon (fenoprofen)
Trilisate (choline magnesium trisalicylate)
Celebrex (celecoxib)
Indocin (indomethacin)
Naprosyn (naproxen)
Vioxx (rofecoxib)
Clinoril (sulindac)
Lodine (etodolac)
Oruvail (ketoprofen)
Voltaren (diclofenac)
Pain Relievers
Acetaminophen (Tylenol)

Codeine (Vicodin, Tylenol 3)

Propoxyphene (Darvon/Darvocet)

Other:

Auranofin, gold pills (Ridaura)

Gold shots (Myochrysine or Solganol)

Hydroxychloroquine (Plaquenil)

Penicillamine (Cuprimine or Depen)

Disease Modifying Antirheumatic Drugs (DMARDS)
Methotrexate (Rheumatrex)

Azathioprine (Imuran)

Sulfasalazine (Azulfidine)

Quinacrine (Atabrine)

Cyclophosphamide (Cytoxan)

Cyclosporine A (Sandimmune or Neoral)

Etanercept (Enbrel)

Infliximab (Remicade)

Prosorba Column

Other:

Patient’s Name
Date
Patient History Form © 1999 American College of Rheumatology
PAST MEDICATIONS Continued
Osteoporosis Medications
Estrogen (Premarin, etc.)

Alendronate (Fosamax)

Etidronate (Didronel)

Raloxifene (Evista)

Fluoride

Calcitonin injection or nasal (Miacalcin, Calcimar)

Risedronate (Actonel)

Other:

Gout Medications
Probenecid (Benemid)

Colchicine

Allopurinol (Zyloprim/Lopurin)

Other:

Tamoxifen (Nolvadex)

Tiludronate (Skelid)

Cortisone/Prednisone

Hyalgan/Synvisc injections

Herbal or Nutritional Supplements

Others
Please list supplements:
Have you participated in any clinical trials for new medications? Yes No
If yes, list:
Patient’s Name
Date
Patient History Form © 1999 American College of Rheumatology
ACTIVITIES OF DAILY LIVING
Do you have stairs to climb? Yes No If yes, how many?
Relationship and age of each
How many people in household?
Who does most of the housework?
Who does most of the shopping?
Who does most of the yard work?
On the scale below, circle a number which best describes your situation; Most of the time, I function…
1
VERY
POORLY
2
POORLY
3
4
OK
WELL
5
VERY
WELL
Because of health problems, do you have difficulty:
(Please check the appropriate response for each question.)
Usually
Sometimes
No
Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.)........................................................

Walking? ...............................................................................................................................................................

Climbing stairs?.....................................................................................................................................................

Descending stairs?................................................................................................................................................

Sitting down?.........................................................................................................................................................

Getting up from chair?...........................................................................................................................................

Touching your feet while seated?..........................................................................................................................

Reaching behind your back?.................................................................................................................................

Reaching behind your head? ................................................................................................................................

Dressing yourself? ................................................................................................................................................

Going to sleep? .....................................................................................................................................................

Staying asleep due to pain?..................................................................................................................................

Obtaining restful sleep? ........................................................................................................................................

Bathing?................................................................................................................................................................

Eating?..................................................................................................................................................................

Working?...............................................................................................................................................................

Getting along with family members? .....................................................................................................................

In your sexual relationship? ..................................................................................................................................

Engaging in leisure time activities? .......................................................................................................................

With morning stiffness?.........................................................................................................................................

Do you use a cane, crutches, as walker or a wheelchair? (circle one)..................................................................

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
Patient History Form © 1999 American College of Rheumatology
Health Assessment Questionnaire
Stanford University School of Medicine – Division of Immunology & Rheumatology
Name _________________________________
Date _________________________
 Please check the response that best describes your usual abilities
OVER THE PAST WEEK:
(FOR OFFICE
USE ONLY)
DRESSING & GROOMING
Are you able to: - Dress yourself, including tying shoelaces and doing buttons?
- Shampoo your hair?
   
   
ARISING
Are you able to: - Stand up from a straight chair?
   
- Get in and out of bed?
   
EATING
Are you able to: - Cut your meat?
   
- Lift a full cup or glass to your mouth?
   
- Open a new milk carton?
   
WALKING
Are you able to: - Walk outdoors on flat ground?
   
- Climb up five (5) steps?
   
 Please check any AIDS OR DEVICES that you usually use for any of these activities:
 Cane
 Built-up or special utensils
 Special or built up chair
 Wheelchair
 Crutches
 Devices used for dressing
 Walker
 Other (specify:) _______________________________________________________________
 Please check any categories for which you usually need HELP FROM ANOTHER PERSON:
 Arising
 Eating
 Walking
 Dressing and grooming
HIGHEST
SCORE
Please check the response that best describes your usual abilities
OVER THE PAST WEEK:
HYGIENE
(FOR OFFICE
USE ONLY)
Are you able to: - Wash and dry your body?
   
- Take a tub bath?
   
- Get on and off the toilet
   
HIGHEST
SCORE
REACH
Are you able to: - Get down a 5-pound object (like a bag of sugar) from just above your head?
- Bend down to pick up clothing from the floor?
   
   
GRIP
Are you able to: - Open a car door?
   
- Open Jars which have been previously opened?
   
- Turn faucets on and off?
   
ACTIVITIES
Are you able to: - Run errands and shop?
   
- Get in and out of the car?
   
- Do chores such as vacuuming or yard work?
   
 Please check any AIDS OR DEVICES that you usually use for any of these activities:
 Raised toilet seat  Long-handled tool for bathroom
 Bathtub bar
TOTAL
÷
 Bathtub seat
 Long-handled tool for reach
 Other (specify :)
 Toilet grip bar
 Jar opener (for jars previously opened )
__________________________
 Please check any categories for which you usually need HELP FROM ANOTHER PERSON:
 Hygiene
 Reach
 Gripping and opening things
 Errands and chores
Place a vertical (l) mark on the line to indicate the severity of pain due to your illness:
No Pain
0
Severe Pain
____________|____________|____________|____________|____________|____________|____________|____________|____________|____________
Number of
answered groups
=
TOTAL HAQ
DISABILITY
SCORE
10
TOTAL PAIN
SCORE
DEMOGRAPHIC INFORMATION
Oklahoma Arthritis Center, P.C.
Patient Information
1701 S. Renaissance Blvd. #110
Edmond, Oklahoma 73013
Phone: 405-844-4978
Fax: 405-844-0562
Name
DOB
SSN
Address
Marital Status
City
Home Phone
Cell Phone
State
Work Phone
Zip
E-Mail
Preferred Method of Contact: Phone E-Mail Text Message
Employer
Referring Physician
Primary Care Physician
Insurance
Primary Insurance
Member ID #
Group #
Insurance Claims Address
Insurance Claims Contact Number
Policy Holder
Policy Holder SSN
DOB
Secondary Insurance
Secondary Member ID #
Secondary Insurance Policy Holder
Policy Holder SSN
Self
Parent
Secondary Group #
DOB
Secondary Claims Address
Spouse
Self
Spouse
Parent
Secondary Claims Contact Number
Emergency Contact
Name
Relationship
Phone
 Check here to Allow disclosure of protected health information to your emergency contact
Preferred Language
Race
Gender Date of Birth
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Do Not Report
Ethnicity
Demographics
 Hispanic or Latino
 Not Hispanic or Latino
 Do Not Report
Permission of Disclosure of Protected Health Information (Optional)
I, «PName» authorize Oklahoma Arthritis Center to disclose my health information to the persons listed below. This information may include,
appointment times or changes, test results, medications, doctor and/or nurse reports, or any other information this office has about me. I also
authorize Oklahoma Arthritis Center to leave telephone messages regarding appointment times or changes, test results, medications, doctor
and/or nurse reports, requests to return calls, financial account information, or any other information this office has about me.
 Please check this box if you DO NOT want messages left on your telephone
Name
______________________________
Relationship
____________
Name
______________________________
Relationship
____________
__
______________________________
____________
______________________________
____________
__
By Oklahoma law, we are required to notify you that the information authorized for release may include records which may indicate the presence of a communicable
or venereal disease which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, also known as
Acquired Immune Deficiency Syndrome (AIDS).
Notice of Privacy Practices
By signing below, I acknowledge receipt of Oklahoma Arthritis Center’s “Notice of Privacy Practices.” I also authorize the release of medical
information required to process all claims on my behalf. I also authorize payment of insurance benefits from those claims be made payable to
Oklahoma Arthritis Center. I understand I am financially responsible for any charge not covered by my insurance.
X__________________________________________________
Patient or Authorized Person Signature
Date
_________________________________________________
OAC Staff Signature
Date

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