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Eastside Orthopedics & Sports Medicine

PATIENT REGISTRATION FORM

May we leave a message on all numbers? *

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Below is required by Federal Statistics and Administration reporting for medical research purposes

Race: *

decline to answer American Indian or Alaska Native Asian Native Hawaiian or Pacific Islander White Black or African American

Ethnicity: *

decline to answer Hispanic or Latino Not Hispanic or Latino

Language Preference: *

Guarantor (If patient is under 18 years of age) *

Yes No

Relationship to patient *

Primary insurance Information

Does your insurance require a referral ? *

Yes No

Secondary Insurance Information *

Yes No

ACCIDENT/INJURY INFORMATION *

Yes No

Date of injury or onset of symptoms? *

Did this injury occur at work? *

Yes No

Auto Accident? *

Yes No

Assignment of Benefits: I hereby authorize the release of any medical information necessary to process insurance claims. I authorize direct payment to Bret T. Kean, MD, Paul D. Ruesch, MD, Akash Gupta, MD and Heather Beissinger MS, PA-C and East *

Check here if you would like to receive occasional important updates about our clinic, health tips, and marketing emails regarding our services.

We will not distribute your information to any third party at any time. Our privacy policy can be found at https://www.eosdocs.com/privacy-policy/

Medical History Intake Form

What is your approximate weight and height? *

Referred here by: (check one) *

Name of Person/Physician making referral:

Parentheses List Current Treating Physicians (including PCP):

Describe the reason for your visit:

Body part to be examined: *

How did your symptoms/injury begin? (describe in detail please) *

Approximate date symptoms began or date of injury: *

New or old injury *

New Old

On a scale of 1-10 (10 being most severe) circle the # that best describes your pain: *

Resulting from: (check which applies) *

Are Symptoms: *

Check all that apply: *

What makes symptoms worse?

What makes symptoms better?

What previous form of treatment have you had for this problem? (medications, therapy, surgery, injections)

DO YOU HAVE ANY DRUG ALLERGIES? *

Yes No

If yes, name the drug and describe the reaction, please be specific. (Example: rash, nausea, shortness of breath, etc)

CURRENT MEDICATIONS:

PREFERRED PHARMACY NAME:

PAST SURGICAL HISTORY

Previous Type of Operation- Please include year performed

Any previous fractures? *

Yes No

Do you currently smoke? *

Yes No

Have you ever smoked? *

Yes No

Use chewing tobacco? *

Yes No

Use smokeless tobacco? *

Yes No

Do you consume alcohol? *

Yes No

History of Abuse: *

Yes No

Have you ever had a problem with drug use? *

Yes No

If yes

Past Current

Do you participate in recreational drug use? *

Yes No

If yes, or in the past, list type and amount:

Have you ever used intravenous drugs? *

Yes No

If yes

Past Current

Marital Status *

Single Married Widowed Divorced

Please list all sports and hobbies you are involved in:

REVIEW OF SYSTEMS (Do you currently have or had a history of the following? Please check all that apply

GENERAL *

Are you?

Right handed? Left handed?

CARDIOVASCULAR *

UROLOGIC/REPRODUCTIVE *

NEUROLOGICAL/PSYCHIATRIC *

EYE, EAR & THROAT *

GASTROINTESTINAL *

MUSCULOSKELETAL *

DERMATOLOGIC *

Rash Unhealing Ulcers None

HEMATOLOGIC *

RESPIRATORY *

BLOODBORNE PATHOGENS *

HIV / AIDS Hepatitis Other None

SITES OF INFECTION *

Please check if any of your family(parents, brothers, sisters, grandparents) have a history of the following: *

I have read and understood the Notice of Privacy Practices (see website) or you may request a copy *

Yes No

I have read and understood the Patient Financial Policy (see website) or you may request a copy *

Yes No

I authorize the following to receive my medical information: *

Spouse Primary Care Physician Other: None

PATIENT REGISTRATION FORM

Emergency Contact

Medical History Intake Form

CURRENT MEDICATIONS:

PAST SURGICAL HISTORY

Social History

REVIEW OF SYSTEMS (Do you currently have or had a history of the following? Please check all that apply

FAMILY HISTORY

I, as the patient, state the information is correct and accurate to the best of my knowledge. *