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Chris Cornett, M.D. Adult Spine Surgery Cindy Fibranz, LPN 402-559-6628 ORTHOPAEDICS MRN: ________________ NEW PATIENT INFORMATION FORM Date: ________________ Time: _______________ Name: ______________________________________________________________________________ Height: ______________ Weight:______________ Age:____________ BMI: __________________ Reason for today’s visit: ______________________________________________________________ ____________________________________________________________________________________ Date of injury or onset of complaints: _____________________________________________________ Is this injury work related? Yes No; Employer: _________________________________________ Currently Working? Yes No; Last day worked: _________________________________________ Auto Accident? Yes No Primary Care Physician and Phone Number: ________________________________________________ Referring Physician (If not the same as Primary Care Physician): ________________________________ ____________________________________________________________________________________ Medical Problems Eye, Ear, Nose, Throat Heart Disease Lung Disease Kidney/Liver Disease Arthritis/Bone/Joint Muscle Disease YES NO Please detail ALL “YES” ANSWERS Diabetes Epilepsy Cancer Vascular Disease Thyroid Disease High Blood Pressure Bleeding/Clotting Disorders Psychiatric Problems Other Surgeries (type and date):______________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Hospitalizations (other than for surgeries above): ___________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Orthopaedic Clinic | 989265 Nebraska Medical Center | Omaha, NE 68198-9265 Page 1 of 3 PH: 402-559-8000 | FX: 402-559-8746 | www.unmc.edu/orthosurgery Chris Cornett, M.D. Adult Spine Surgery Cindy Fibranz, LPN 402-559-6628 ORTHOPAEDICS Current Medications (list all medications including prescription, over the counter, vitamins & supplements): ________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Allergies (or bad reactions) to medications: ________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Social History: Do you use Tobacco? Yes No Amount/Duration: __________________________________ Do you use Alcohol? Yes No Amount/Duration: __________________________________ Do you use Recreational Drugs? Yes No If Yes, what substance? _______________________ Amount/Duration: ________________________ Occupation (w/brief job description):_______________________________________________________ ____________________________________________________________________________________ Highest Level of Education: _____________________________________________________________ Recreational Activities: _________________________________________________________________ Family History: ______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ System Review: Check those that apply Headache/dizziness/visual disturbances Throat trouble, ringing in ears, runny nose Chest pain/palpitations/irregular heart beat Shortness of Breath/cough Heartburn/nausea/vomiting Burning/frequency of urination or vaginal discharge Muscle/bone/joint/pain or stiffness Changes in skin color/texture/moles or rashes Explain Swelling/discoloration/temperature change of extremity Loss of sensation Lower back pain Fever/chills/sweats/fatigue Easy bruising or bleeding disorder Weight loss or gain Excessive thirst or hunger Excessive worry/anxiety/depression or trouble sleeping Dietary restriction Glasses or contacts Dentures or partials Orthopaedic Clinic | 989265 Nebraska Medical Center | Omaha, NE 68198-9265 Page 2 of 3 PH: 402-559-8000 | FX: 402-559-8746 | www.unmc.edu/orthosurgery Chris Cornett, M.D. Adult Spine Surgery Cindy Fibranz, LPN 402-559-6628 ORTHOPAEDICS Patient Signature: ______________________________________________ Date: _________________ Physician Signature of Initial Review: _______________________________ Date: ________________ Periodic updates: Date: _________ Changes made? Yes__ No__ Physician/staff signature: _________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Periodic updates: Date: _________ Changes made? Yes__ No__ Physician/staff signature: _________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Orthopaedic Clinic | 989265 Nebraska Medical Center | Omaha, NE 68198-9265 Page 3 of 3 PH: 402-559-8000 | FX: 402-559-8746 | www.unmc.edu/orthosurgery
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