Download Patient Intake Form Esposito

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