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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
PEDIATRIC ORTHOPAEDICS INTAKE INFORMATION Medical Record #: __________ Patient’s Name: _________________________________________________ Nickname: _____________ (last) (first) (middle initial) Date of Birth: ______________________ Phone #: (include area code) _____________________________________ Grade in School: ______________ Complete address: _____________________________________________________________________________ Primary Physician: _____________________________________________________________________________ (name, city, state) Referring Physician: ____________________________________________________________________________ (name, city, state) MEDICAL HISTORY AGE: Years: ______ Months: ______ Sat up alone ______ months Gender: Male:______ Cruised around furniture ______ months Female:______ Walked ______ months Any difficulties during pregnancy:___________________________________________________________________________ Any difficulties at birth or soon thereafter (breech, cesarean, respiration, etc) _________________________________________ Birthweight: pounds_____ ounces_______ Reason for seeing pedi ortho: ______________________________________________________________________________ a. How long has this problem been present: ____________________________________________________________ b. Previously treated? Y / N How:_______________________________________________________________ Date of accident/injury/onset:______________________________________________________________________________ Where seen first (Emergency Room, Primary Care, Office) Name of Facility:_________________________________________ Name of Doctor: __________________________________________________________________________________ How did the injury occur:_________________________________________________________________________________ Duration of symptoms: ____________________________________________________________________________________ Other medical problems: ___________________________________________________________________________________ Allergies: yes/no: to what? _____________________________ Allergies: (substances/meds) ____________________________ Medications (include dosage): ______________________________________________________________________________ ______________________________________________________________________________ Previous hospitalizations/surgeries (include dates): ______________________________________________________________ PEDIATRIC ORTHOPAEDICS Relationship to patient: (if different from patient): _______________________________________________________________ Father’s Name: ____________________________________ DOB:_________________ Soc. Sec #:_____________________ Address: ____________________________________________ Phone #: __________________ Marital Status: __________ (include city, state, zip) Occupation:__________________________________________ Employer: _____________________________________ Address: ____________________________________________________ Phone: _____________________________________ (include zip) Mother’s Name: ____________________________________ DOB:_________________ Soc. Sec #:____________________ Address: ____________________________________________ Phone #: __________________ Marital Status: __________ (include city, state, zip) Occupation:__________________________________________ Employer: _____________________________________ Address: ____________________________________________________ Phone: _____________________________________ (include zip) Brothers and sisters: Name Age ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Have siblings been under a physician’s care or do they have orthopaedic problems: __________ If so, for what/what kind? _________________________________________________________________________________ Have siblings been under a physician’s care or do they have orthopaedic problems: __________ If so, for what/what kind? _________________________________________________________________________________ ******************************************************************************************************* Insurance information : Statement to be sent to: _____________________________________________________________ Insur. company (List primary carrier first):_______________________________ Policy Holder: ________________________ Insurance address: ________________________________________________________________________________________ (include city, state, zip) Soc sec# (if different than above): ____________________________ Relationship to patient: ___________________________ Policy #: ____________________________________________________ Group #: _______________________________ Caseworker name and phone number: ________________________________________________________________________ Additional Insurance information: Statement to be sent to: _____________________________________________________ Insur. company:_____________________________________________________ Policy Holder: ________________________ Insurance address: ________________________________________________________________________________________ (include city, state, zip) Soc sec# (if different than above): ____________________________ Relationship to patient: ___________________________ Policy #: ____________________________________________________ Group #: _______________________________ Caseworker name and phone number: ________________________________________________________________________ THANK YOU