Patient Information Form
Date:
Account Number:
Name:
Address:
Home Phone:
Work Phone:
Cell Phone:
Employer:
Employer Address:
Email Address:
Social Security Number:
Sex:
Date of Birth:
Marital Status:
Emergency Contact:
Emergency Contact Phone Number:
Primary Care Physician:
Referring Physician:
Pharmacy Name:
Pharmacy Address / Phone Number:
Which of the following coverage types are
you going to treat under (circle one):
Has your insurance changed since the last
time you were here or have you received new
insurance cards (circle one):
Subscriber’s name
(Primary Group Health Insurance):
Subscriber’s Date of Birth
(Primary Group Health Insurance):
Subscriber’s Relationship
(Primary Group Health Insurance):
Subscriber’s name
(Secondary Group Health Insurance):
Subscriber’s Date of Birth
(Secondary Group Health Insurance):
Subscriber’s Relationship
(Secondary Group Health Insurance):
Maiden Name:
Referred By:
Patient Signature
Group Health Insurance
Workman’s Compensation
Motor Vehicle Insurance
Yes
No
Date
______
Patient Information Form
Why are we collecting this information?
According to the standards of the Center for Medicare Services, Meaningful Use is the act of using a Certified Electronic Health
Record in a “meaningful way” over the course of 3 stages.
Meaningful Use means that an Eligible Professional must meet core and menu objectives within the EHR. By doing so, an
organization will be able to improve quality, safety, and efficiency of patient care. The patient and their families will also have a greater role
in the management of their healthcare.
Evidence shows that racial, ethnic, and language-based disparities persist in healthcare, leaving the most vulnerable populations at
risk. We don’t know why disparities occur, but these gaps in care are associated with higher mortality rates.
The collection of this information will be used to measure delivery of healthcare services; collecting accurate data is the basic
foundation to identify differences and improve the quality of care. This information provides the practice with an accurate snapshot and
trending of the patient population and the need for more care interventions, such as: interpreter services, translated patient healthcare
information, improving rates of preventive services, and cultural competency training for staff.
The intention is that through the collection of this data, the disparities will be identified and care will be aligned regardless of these
disparities so we can all benefit from the same quality of medical care.
Account Number:
Name:
Race:
(Please select all that
apply)
American Indian
or Alaskan Native
Black or
African American
Native Hawaiian
or Other Pacific Islander
Asian
Declined
White
Declined
Hispanic or Latino
Non-Hispanic or Latino
Amharic
Arabic
Armenian
Bengali
Cajun
Chinese
Croatian
Czech
Danish
Declined
Dutch
English
Finnish
Formosan
French
French Creole
German
Greek
Gujarathi
Hebrew
Hindi
Hungarian
Ilocano
Italian
Japanese
Korean
Kru
Lithuanian
Malayalam
Mandarin
Miao (Hmong)
Moni-Khmer (Cambodian)
Navaho
Norwegian
Panjabi
Pennsylvania Dutch
Persian
Polish
Portuguese
Romanian
Russian
Samoan
Serbocroatian
Slovak
Spanish
Swedish
Syriac
Tagalog
Thai (Laotian)
Turkish
Ukrainian
Vietnamese
Yiddish
Other: ___________
Ethnicity:
(Please select one only)
Primary Language
Spoken:
(Please select all that
apply)
Patient Signature
Date
______
IMPORTANT PATIENT POLICIES
A.
FINANCIAL POLICY AND ASSIGNMENT: I, the undersigned, understand that, as a courtesy to its patients, CH Hospital of
Allentown, L.L.C, Coordinated Health Orthopedic Hospital, L.L.C., and/or CHS Professional Practice, P.C. (hereinafter also collectively referenced
as “CH”) may seek reimbursement from an insurance company who may be responsible for medical services, devices and/or supplies provided to the
below identified patient. I agree to: (a) provide CH with complete and accurate information concerning said insurance coverage; (b) assign any such
benefits or rights to said insurance coverage to CH and authorize payment of benefits or rights related thereto to CH; (c) be financially responsible for
all charges by CH that are not covered by and/or are not timely reimbursed by said insurance (in whole or in part), including (but not limited to) copayments and deductibles for and/or coverage denials by said insurance; (d) be responsible for determining whether insurance coverage exists and the
extent of said coverage in advance of the below identified patient being provided with medical services, devices and/or supplies by CH; (e)
immediately, upon the request of CH, make any and all payments owed to CH for medical services, devices and/or supplies provided to or to be
provided to the below identified patient; (f) reimburse CH for all reasonable collection service and/or attorney fees and for other reasonable costs
incurred by CH related to its efforts to collect payments owed to CH for medical services, devices and/or supplies provided to the below identified
patient and for any service fees or other charges assessed against CH related to a check issued for said payment of medical services, devices and/or
supplies for the below identified patient; and (g) determine, in advance of the below identified patient’s visit to CH, whether a referral is required by
the insurance company I have identified as being responsible for payment.
Initials of Patient (or Parent/Guardian if Patient is a Minor)
B.
AUTHORIZATION OF CARE/TREATMENT: I hereby authorize CH and its physicians, physician assistants, podiatrists,
chiropractors, physical therapists and/or other employees and/or agents to provide such services, devices and/or supplies that they deem reasonable
and appropriate for the below identified patient. I agree that any revocation of this authorization shall be done in a writing signed by me and
personally delivered to CH. I understand that such a revocation shall not be effective as to a health care professional at CH until I personally serve
that health care professional with said notice. I further understand that no guarantee of a cure or an outcome of care/treatment can be or is given by
CH or its physicians, physician assistants, podiatrists, chiropractors, physical therapists and/or other employees and/or agents.
Initials of Patient (or Parent/Guardian if Patient is a Minor)
C.
DISCLOSURE OF FINANCIAL INTEREST IN REFERRALS AND YOUR FREEDOM TO CHOOSE ALTERNATE
PROVIDER: I UNDERSTAND THAT CH AND/OR ITS PHYSICIANS AND/OR ITS OTHER HEALTH CARE PROVIDERS MAY REFER
THE BELOW IDENTIFIED PATIENT FOR A MEDICAL SERVICE, PRODUCT OR DEVICE OR TO A FACILITY OR BUSINESS IN WHICH
ONE OR MORE OF OUR PHYSICIANS HAS A FINANCIAL INTEREST. IF THAT HAPPENS, I UNDERSTAND THAT I WILL ALWAYS
HAVE THE FREEDOM TO CHOOSE AN ALTERNATE PROVIDER. I FURTHER UNDERSTAND THAT A LIST OF THE FACILITIES OR
BUSINESSES IN WHICH ONE OR MORE OF OUR PHYSICIANS HAS A FINANCIAL INTEREST WILL BE PROVIDED TO ME UPON MY
REQUEST.
Initials of Patient (or Parent/Guardian if Patient is a Minor)
D.
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES: CH has a detailed document called
“Notice of Privacy Practices”. It contains information about the policies and practices of CH regarding patient privacy. By signing below, I
acknowledge the following about the “Notice of Privacy Practices” of CH: (a) I was offered a copy of it on the below date; and (b) I may review a
copy of it on the Internet by going to www.coordinatedhealth.com and/or by requesting it at the front desk of any office of CH. Further, I agree that
the pharmacy for the below identified patient and CH may exchange information about my prescription history in accordance with said Notice of
Privacy Practices.
Initials of Patient (or Parent/Guardian if Patient is a Minor)
E.
ACKNOWLEDGEMENT OF PREVENTATIVE CARE COMMUNICATION OPTIONS: I understand that: (a) reminders for
preventative/follow-up care may be sent to me by CH by any of the following communication methods: phone, mail and/or patient portal secure
messaging; and (b) these reminders shall be sent to me via mail until I have completed registration with CH’s patient portal (which shall then result in
future reminders being communicated to me via patient portal secure messaging) or until I request a change in the method that these reminders for
preventative/follow-up care are communicated to me. A change request (including a request to decline all such reminders for preventative/follow-up
care) must be sent in writing to: Compliance Officer, Coordinated Health, 3435 Winchester Road, 4 th Floor, Allentown, PA 18104.
Initials of Patient (or Parent/Guardian if Patient is a Minor)
I HAVE REVIEWED THE ABOVE AND AGREE WITH ANY TERMS AND/OR CONDITIONS SET FORTH THEREIN.
«PNumber»
Patient Account Number
«PName»
Patient Name
Date
Signature of Patient or Parent/Guardian (if Patient is a Minor)
Version: Chiro New PT Split 20150224
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
TO EMPLOYER/PROSPECTIVE EMPLOYER AND/OR TO SCHOOL
I, the undersigned, authorize the doctors, physician assistants, physical therapists, nurses, case managers and/or other
employees/agents of CHS Professional Practice, PC (CHS), Coordinated Health Orthopedic Hospital, LLC (CHOH), and CH Hospital
of Allentown, LLC (CHHA) [hereinafter also collectively referenced as “CH”] to disclose the protected health information referenced
in this Authorization to the following school and/or employer/prospective employer (and/or the officers, employees and/or agents
designated by it/them to receive said protected health information):
___________________________________________________________________________________.
Print Name of School and/or Employer/Prospective Employer
The protected health information to be disclosed is the entire designated record set and/or information contained therein,
which may include (but is not limited to) historical, examination, drug/alcohol, mental health and/or HIV information and/or
drug/alcohol testing results, except the following:
______________________________________________________________________________.
Print “None” if no exceptions apply
This protected health information is being disclosed at the request of the undersigned.
This Authorization shall be in effect for twelve (12) months from the below date.
I understand that I have the right to revoke this Authorization in writing at any time by sending written notification to:
Privacy Officer, c/o Operations, Coordinated Health, 3435 Winchester Rd., Allentown, PA 18104. I understand that CH shall need a
reasonable time to process my revocation. I agree that five (5) business days after CH receives said revocation is a reasonable period
of time for CH to process my revocation. Consequently, I understand that my revocation will not be effective until five (5) business
days after it is received by the Privacy Officer.
I understand that CH may condition my examination/evaluation on whether I execute this Authorization if the primary
purpose of the creation of this protected health information is for disclosure to the aforesaid school or employer or prospective
employer (e.g., a pre-employment physical or a physical to participate in athletics). Otherwise, CH shall not condition its medical care
of the below identified patient on whether I execute this Authorization.
I understand that information used or disclosed pursuant to this Authorization may be used or disclosed by the recipient and
may no longer be protected by Federal or State law.
I hereby release CH and/or their officers, representatives, employees and/or agents from any and all claims related to their
use or disclosure of information pursuant to this Authorization. This release shall apply to my heirs, beneficiaries, successors and/or
assignees.
By my signature below, I acknowledge that I have received a copy of this document.
«PNumber»
Patient Account Number
«PName»
Patient Name
Date
Signature of Patient or Legal Guardian
Version: Chiro New PT Split 20150224
Outpatient Department Coinsurance Notice & Frequently Asked Questions
About Hospital Outpatient Department (or Provider Based) Billing for Office Visits
What is Provider (or Hospital) Based Status?
The Centers for Medicare and Medicaid Services (CMS) permit certain off-campus hospital outpatient department locations to charge a
“facility fee” in addition to the provider’s professional fee. This occurs when an off-campus hospital outpatient department (such as a
physician office or imaging suite) is owned and operated as part of a hospital and must comply with quality and safety standards
established by the Department of Health and Joint Commission for Accreditation of Hospitals.
Has Coordinated Health incurred costs to become Provider Based?
Yes. Satisfying the compliance requirements mentioned above has caused and will continue to cause significant equipment, construction
and personnel expenses for Coordinated Health.
Why did these outpatient offices of Coordinated Health become part of a hospital?
To improve the experience of its patients. Being Provider Based has resulted in quality and safety improvements (e.g., from increased
oversight and integration and from new equipment and facilities).
How does this affect billing?
CMS patients and patients of some commercial insurances who receive care in one of Coordinated Health’s Provider Based (or
outpatient) offices or clinics (such as a physician office) will receive two (2) charges for their visit (except for physical therapy 1). One is
the fee for the service rendered by the professional, and one is for the facility fee (i.e., the charge by CH Hospital of Allentown LLC).
This facility fee is the charge for administrative and other costs that are required to support the hospital-based office, including but not
limited to office space, nursing staff, clerical support, and supplies. Your total liability resulting from these two (2) charges could be
higher, lower or the same as if you received one charge. As always, it is your responsibility to determine whether insurance coverage
exists and the extent of coverage for these two (2) charges in advance of services being rendered.
If I am a Medicare patient, what is my potential co-insurance liability for a visit to a Provider Based office?
In accordance with Medicare’s laws and regulations, you will incur a co-insurance liability to CH Hospital of Allentown at a Provider
Based office that you would not have otherwise incurred. In general, Medicare pays 80% of the “allowed” amount, and the remaining
20% is your co-insurance liability. Your actual co-insurance liability will depend upon the actual services furnished by the Provider
Based office. For example, co-insurance balances for an average follow up visit for an established patient (99213) would be
approximately $17.55 for the hospital (facility) charge and $10.12 for the physician charge. Please note that secondary coverage (if
applicable) may pay these balances.
Which Coordinated Health outpatient offices or clinics are Provider Based?
Bethlehem: 2775 Schoenersville Road, 2300 Highland
Avenue, 2030 Highland Avenue, 3100 Emrick Avenue
Wind Gap: 1411 Jacobsburg Road
Lehighton: 239 North First Street
East Stroudsburg: 505 Independence Road, 511 VNA
Road
Allentown: 1621 North Cedar Crest, 1503 North Cedar
Crest, 1405 North Cedar Crest, 250 Cetronia Road
Brodheadsville: 111 Switzgable Drive
Hazleton: 1097B North Church Street
If you have any questions regarding your bill, please contact our Central Billing Office at 610- 861-8080 or 1-877-247-8080 and follow
the prompts.
«PNumber»
Patient Account Number
«PName»
Patient Name
Date
Signature of Patient or Legal Guardian
1
Physical therapy has only 1 bill, and it is from CH Hospital of Allentown LLC.
Version: Chiro New PT Split 20150224
Review of Systems
Patient Name: «PName»
MRN: «PNumber»
DOB: «PDOB»
Today’s Date: 5/15/2015
Please answer the following questions to the best of your ability.
In the past 6 months have you had ANY of the following?
General:
1. Recent unexplained changes in weight
2. Unexplained Fevers
3. Night sweats
4. Weakness or fatigue
5. Loss of appetite
6. Immune deficiencies
7. Trouble sleeping
8. Daytime sleepiness
Respiratory:
□
□
□
□
□
□
□
□
N
N
N
N
N
N
N
N
□
□
□
□
□
□
□
□
Musculo-skeletal:
9. Joint pain
10. Joint swelling
11. Muscle pain
12. Muscle cramps
13. History of back pain
14. Trouble walking
□
□
□
□
□
□
N
N
N
N
N
N
□
□
□
□
□
□
□
□
□
□
□
N
N
N
N
N
□
□
□
□
□
Skin:
15. Rashes
16. Changes in skin
17. Changes in nails
18. Changes in hair (e.g.-dryness)
19. Non-healing sores
Y
Y
Y
Y
Y
Y
Y
Y
Eyes:
21. Eye pain(discomfort)
22. Double vision
23. Blurred vision
Ears, Nose & Throat:
24. Ringing in the ears
25. Ear pain
26. Nasal discharge
27. Nasal bleeding
28. Sinus pain
29. Soreness
30. Hoarseness
31. Difficulty swallowing
32. Dry mouth
33. Snoring
□
□
□
□
□
□
□
N
N
N
N
N
N
N
□
□
□
□
□
□
□
Y
Y
Y
Y
Y
Y
Y
Hematological/Lymphatic:
41. Swollen glands
Y 42. Bruise easily
Y Neurological:
Y 43. Fainting
Y 44. History of seizures
Y 45. Memory loss
Y 46. Numbness
47. Tingling
Y 48. Loss of bladder control
Y 49. Loss of bowel control
Y 50. Mood swings
Y 51. Depression
Y 52. Anxiety
Head:
20. Frequent headaches
34. Chest Pain
35. Wheezing
36. Coughing □productive □ dry
37. History of tuberculosis
38. History of smoking
39. Shortness of breath/difficulty breathing
40. History of pneumonia
□ N □ Y
□ N □ Y
□
□
□
□
□
□
□
□
□
□
N
N
N
N
N
N
N
N
N
N
□
□
□
□
□
□
□
□
□
□
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Cardiovascular:
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
53. History of heart problems
□ N □ Y
54. High blood pressure
□ N □ Y
55. Low blood pressure
□ N □ Y
56. Chest pains or palpitations
□ N □ Y
If yes: What causes it? ____________________________
How long does it last? ______________________
What makes it better? ______________________
What make it worse? _______________________
Where is it? ______________________________
What does it feel like? ______________________
57. Shortness of breath w/normal activities
58. Dizziness
59. Loss of Consciousness
60. Leg swelling
61. Lightheadedness
□
□
□
□
□
N □
N □
N □
N □
N □
Y
Y
Y
Y
Y
Version: Chiro New PT Split 20150224
62. Abdominal pain
63. Frequent diarrhea
64. Constipation
65. Heart burn
66. Unexplained nausea or vomiting
67. History of hepatitis
68. Ulcers
69. Change in appetite
70. Dark or bloody stool
□
□
□
□
□
□
□
□
□
N
N
N
N
N
N
N
N
N
□
□
□
□
□
□
□
□
□
Y
Y
Y
Y
Y
Y
Y
Y
Y
□
□
□
□
□
□
□
N
N
N
N
N
N
N
□
□
□
□
□
□
□
Y
Y
Y
Y
Y
Y
Y
□
□
□
□
□
□
□
N
N
N
N
N
N
N
□
□
□
□
□
□
□
Y
Y
Y
Y
Y
Y
Y
Urinary:
71. Frequent urination
72. Painful urination
73. Urinary infections
74. Urinary urgency
75. Blood in urine
76. Urinary incontinence
77. Get up at night to urinate
Endocrine:
78. History of thyroid problems
79. Heat intolerance
80. Cold intolerance
81. Excessive sweating
82. Recent increased thirst
83. Recent increased appetite
84. Tremors
Integumentary/Breasts (cont.)
87. Change in hair growth, loss, texture
88. Breast or nipple discharge
89. Breast pain
□ N
□ N
□ N
□
□
□
Y
Y
Y
□ N
□
Y
□ N
□
Y
□ N
□ N
□
□
Y
Y
□ N
□ N
□
□
Y
Y
□ N
□
Y
□ N
□
Y
□ N
□ N
□ N
□
□
□
Y
Y
Y
□
□
□
□
□
□
□
□
□
□
Y
Y
Y
Y
Y
Mobility Matters:
90. Do you have any problems with bathing,
dressing or eating
91. Do you have any problem with light
household tasks (e.g. cooking, cleaning or
doing laundry?
92. Do you have difficulty climbing stairs?
93. Do you get shortness of breath doing any
of the above mentioned tasks?
94. Have you fallen in the last 6 months?
95. Do you use an assistive device to walk?
(cane or walker)
96. Do you feel unsteady on your feet?
FOR MEN ONLY
97. History of prostate problems
FOR WOMEN ONLY
98. Personal history of breast disease
99. Family history of breast cancer
100. Have you ever been pregnant?
If YES, how many times?
Integumentary/Breasts:
101. Personal history of ovarian cancer
85. Nodules
□ N □ Y 102. Bleeding or pain during intercourse
86. Change in moles or freckles
□ N □ Y 103. Unusual vaginal itching or burning
104. Vulvar or vaginal itching or burning
105. Pelvic Pain
106. Date of last menstrual period
107. Age during first menstrual period
SPECIAL NEEDS (check all that apply) □ None
□ Religious □ Cultural □ Emotional □ Communication □ Physical □ Medical
N
N
N
N
N
Specify _______________________________________________________________________________________
_____________________________________________________________________________________________
ALLERGIES (Medications, metals, x-ray dyes or other substances) □ Yes □ No
If yes, please list names or allergen and type of reactions:
_______________________________________________________________________________________
_____________________________________________________________________________________________
Have you ever experienced a reaction to anesthesia? □ Yes □ No
If yes, please explain:
_____________________________________________________________________________________________
Patient Signature ________________________________
___________________________ Date _______________
Version: Chiro New PT Split 20150224
The
Arthritis and Osteoporosis Center
at COORDINATED HEALTH
RHEUMATOLOGY PATIENT HISTORY FORM
Date of first appointment: _____________________
Name: «PName»
Age: _____ Sex:
MRN: «PNumber»
□M □F
Birthdate: «PDOB»
Telephone #: Home: _______________________________
Work: ______________________________
Marital Status:
□ Never Married
Spouse/Significant Other:
□ Married
□ Alive/Age ____
□ Divorced
□ Deceased/Age _____
Education (circle highest level attended)
Grade School: 7 8 9 10 11 12
College: 1 2 3 4
Referred here by: (check one)
□ Self
□ Separated
□ Family
□ Widowed
□ Major Illnesses _____________
Graduate School: _____________________
□ 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: ___________________________________________________________
____________________________________________________________________________________________
Date symptoms began (approximate) ______________________________________________________________
Diagnosis: _________________ __________________________________________________________________
Previous treatment for this problem (include physical therapy, surgery, injections) (medications to be listed later)
List the names of other practioners you have seen for this problem: _____________________________________
____________________________________________________________________________________________
Rheumatologic (Arthritis History) at any time have you or a blood relative had any of the following?
Yourself
type
Relative/Relationship
_______
Arthritis (unknown)
_______
Yourself
type
Relative/Relationship
____________________ _
________
LUPUS or SLE
__________________
Osteoarthritis
____________________ _
________
Rheumatoid Arthritis _________________
_______
Gout
_____________________
________
LUPUS or SLE ____________________
_______
Childhood Arthritis
____________________ _
________
Osteoporosis ____________________
Patient’s Name: «PName»
Date: _____________ Physician’s initials: _______
The
Arthritis and Osteoporosis Center
at COORDINATED HEALTH
Name: «PName»
MRN: «PNumber»
Birthdate: «PDOB»
Social History
Do you drink caffeinated beverages? _________
Cups/glasses per day? __________
Past Medical History
Do you now or have you ever had: (check if YES)
Amount per week: ___________________________
How many hours of sleep do you get at night? ______
Do you get enough sleep at night: □ Yes □ No
Other significant illnesses (please list): _____________
Natural or Alternative Therapies (magnets, chiropractic,
massage, over the counter preparations etc.
Do you wake up feeling rested? □ Yes □ No
____________________________________________
□ Cancer
□ Heart Problems
□ Asthma
Do you smoke? □ Yes □ No How Long? ______
□ Goiter
□ Leukemia
□ Stroke
Do you drink alcohol? □ Yes □ No # per week______ □ Cataracts
□ Diabetes
□ Epilepsy
Has anyone ever told you to cut down on your
□ Nervous Breakdown
□ Stomach Ulcers
drinking? □ Yes □ No
□ Rheumatic Fever □ Bad Headaches □ Jaundice
Do you use drugs for reasons that are not medical?
□ Colitis
□ Kidney Disease
□ Pneumonia
If yes, please list: ____________________________
□ Psoriasis
□ Anemia
□ HIV/AIDS
Do you exercise regularly? □ Yes □ No
□ High Blood Pressure □ Emphysema □ Glaucoma
Type: _____________________________________
□ Tuberculosis
____________________________________________
Previous Operations
Type
Year
Reason
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
4. _____________________________________________________________________________________
5. _____________________________________________________________________________________
6. _____________________________________________________________________________________
7. _____________________________________________________________________________________
Any previous fractures: □ Yes □ No Describe: _______________________________________________
Any other serious injuries? □ Yes □ No Describe: ______________________________________________
Family History:
If Living
If Deceased
Age
Health
Age of death
Cause
Father
_______
_________________
______
________________________
Mother
_______
_________________
______
________________________
Number of siblings: _______ Number living: _______ Number deceased ________ List ages of each _______
Health of children: ___________________________________________________________________________
__________________________________________________________________________________________
Patient’s Name: ______________
Date: _____________ Physician’s initials: _______
The
Arthritis and Osteoporosis Center
at COORDINATED HEALTH
Name:
MRN:
Birthdate:
Do you know any blood relative who has or had: (check & give relationship)
□ Cancer ________
□ Heart Disease __________ □ Rheumatic Fever _______
□ Leukemia _______
□ Stroke ________
□ Colitis ______
□ Tuberculosis________
□ High blood pressure ________ □ Epilepsy _______ □ Diabetes ________
□ Bleeding tendency _______
□ Asthma _______ □ Goiter ________
□ Alcoholism _______
□ Psoriasis ________
Drug Allergies: □ Yes □ No To what? ____________________________________________________________
____________________________________________________________________________________________
Type of reaction: ______________________________________________________________________________
Present Medications: (list any medications you are taking such as aspirin, vitamins, laxatives, calcium & other supplements)
Name of Drug
Dose (include strength &
How long have you
# of pills per day)
taken this med?
1. _____________________________________________________________________________________
2. _____________________________________________________________________________________
3. _____________________________________________________________________________________
4. _____________________________________________________________________________________
5. _____________________________________________________________________________________
6. _____________________________________________________________________________________
7. _____________________________________________________________________________________
8. _____________________________________________________________________________________
9. _____________________________________________________________________________________
10. _____________________________________________________________________________________
Past Medications (please review the list of arthritis medications. As accurately as possible, try to remember which medications you have taken,
how long you took the medications, the results of taking the medication & list any reactions you may have had.)
Drug names/Dosage
Length
Helped?
Reactions
□ A lot □ Some □ Not at all
Non-Steroidal Anti-Inflammatory Drugs
Circle any drugs that you have taken in the past
Ansaid (furbiprofen) Arthrotec (diciofenac + misoprosill) Aspirin (including coated aspirin) Celebrex (celecoxb)
Clinoril (sulindac)
Daypro (oxaprozin)
Disalcid (salsalate)
Indocin (indomethacin)
Lodine (etodolac)
Nalfon (fenoprofen)
Naprosyn (naproxen)
Trillsate (choline magnesium trisulicylate)
Patient’s Name: __________
Dolobid (Difiunisal)
Meclomen (meclofenamate)
Oruvail (ketoprefen)
Vioxx (rofecoxlb)
Feldene (piroxican)
Motrin (ibuprofen)
Tolectin (tolmetin)
Voltaren (diclofenac)
Date: _____________ Physician’s initials: ______
The
Arthritis and Osteoporosis Center
at COORDINATED HEALTH
Name:
MRN:
Birthdate:
Length of
Helped?
Pain Relievers
Time Taken
A lot / Some /Not at all
Reactions
Acetaminophen (Tylenol) _______________________□______□______□________________________________
Codeine (Vicodin, Tylenol 3) _____________________ □_____ □______□_______________________________
Propoxyphen (Darvon/Darvocet) _________________ □______□_____ □_______________________________
Other _______________________________________□______ □_____ □________________________________
Disease Modifying Antirheumatic Drugs (DMARDS)
Auranofin, gold pills (Ridaura)
Gold shots (Myochrysine or Solganol)
Hydroxychloroquine (Plaquenil)
Penicillamine (Cuprimine or Depen)
Methotrexate (Rheumatrex)
Azathioprine (Imuran)
Sulfasalazine (Azulfidine)
Cyclophosphamide (Cytoxan)
Cyclosporine A (Sandimmune or Neoral)
Etanercept (Enbrel)
Infliximab® (Remicade)
Adalimumab (Humira)
Other
Osteoporosis Medications
Estrogen (Premarin, etc.)
Alendronate (Fosamax)
Sandromate (Boniva)
Raloxifene (Evista)
Peraperatide (Forteo)
Calcitonin injection or nasal
(Miacalcin, Calcimar)
Risedronate (Actonel)
Other
Other
Patient’s Name: «PName»
A Lot
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________________________
________________________
Some
Not at All
Reactions
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________________
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________________
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________________
________________
________________
Date: _____________ Physician’s initials: _______
The
Arthritis and Osteoporosis Center
at COORDINATED HEALTH
Name:
MRN:
A Lot
Gout Medications
Probenecid (Benemid)
Colchicine
Allopurinol (Zyloprim/Lopurin)
Other
Other
Others
Tamoxlfen (Nolvadex)
Tiludronate (Skelid)
Cortisone/Prednisone
Hyalgan/Synvisc Injections
Some
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Birthdate:
Not at All
Reactions
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_____________________
_____________________
_____________________
_____________________
_____________________
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_____________________
_____________________
_____________________
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_____________________
_____________________
Herbal or Nutritional Supplements
Please list supplements: ______________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Patient’s Name: «PName»
Date: _____________ Physician’s initials: _______
Patient Name:
Account #:
Patient DOB:
Controlled Substance / Narcotic Agreement
The purpose of this Agreement is to prevent misunderstandings between you (the patient) and Coordinated Health (CH)
regarding the pain medications that have been prescribed for you.
You shall NOT:
1.
2.
3.
4.
5.
6.
7.
8.
Use illegal substances, including (but not limited to) marijuana, cocaine, heroin, ectasy, meth or non-prescribed meds.
Seek pain meds or muscle relaxants or sleep meds or tranquilizers from a health care provider other than your prescribing
doctor at CH.
Change your other meds without the permission of your prescribing doctor at CH.
Change your pharmacy for pain meds without the permission of your prescribing doctor at CH.
Drive a motor vehicle or operate any potentially dangerous equipment without the permission of your prescribing doctor at
CH. Further, even if such permission is granted, be aware that you may still be in violation of the law for driving while on
your pain meds.
Share your pain meds or put them in a place where they may be taken by someone else or a pet.
Call for a refill of your pain meds more than 1 week before the refill date (unless you present proof of travel plans that
prevent you from refilling in the week before your refill date).
Alter a prescription from your prescribing doctor at CH in any way.
You shall:
1.
2.
3.
4.
5.
6.
Be prepared to submit to blood or urine testing at each office visit to CH, in order to determine compliance with this
Agreement. [Note: You should not urinate in the 60 minutes before your office visit with CH . You should also be prepared
to pay the costs associated with this blood or urine testing at each office visit with CH.]
Bring all unused pain meds to each office visit with CH.
Use your pain meds as your doctor at CH has prescribed.
Immediately notify your doctor at CH of any significant changes in your pain or any other condition.
See a psychologist or psychiatrist if recommended by your prescribing doctor at CH.
Notify all of your other treating doctors or health care providers of your prescribing doctor at CH and provide an accurate
history of your pain meds to them.
By signing below, I agree that:
1.
2.
3.
4.
5.
6.
The risks and alternatives of the pain medications prescribed for me have been explained to me by my prescribing doctor at
CH. The risks include (but are not limited to) constipation, nausea, vomiting, drowsiness, confusion, itching, depressed
respiration, dependence/addiction, overdose and death (especially if not taken properly).
CH may share my medical records or information regarding my care/treatment with law enforcement agencies & I have NO
expectation of privacy or confidentiality in regards to such.
CH may terminate me as its patient if I fail to abide by this Agreement.
I understand that pain medication is not designed to completely eliminate my pain, but is designed to reduce my pain to
increase my function. I further understand that my initial treatment is a trial.
I understand that my pain meds will NOT be replaced if they are lost, stolen, destroyed, etc….
I shall immediately report to the Emergency Room closest to me if I have any significant change in my pain or condition.
Sign name:
____________________________
Prescribing doctor at CH: __________________
Print name:
___________________________
Pharmacy:
Date of birth:
_
________________________
Date signed:
Version: PMR New PT Split 20150224