Learning Center
Plans & pricing Sign in
Sign Out



									                                MT. ASCUTNEY PHYSICIAN PRACTICES

Patient Name
            Last                           First                    Middle initial

Mailing Address

City                               State                             Zip code

Date of Birth:                             Sex              Social Security #

Home Phone #                                        Marital Status

Cell Phone #                                        Primary Care Doctor

Patient Employer                                            Phone #

Employer Address

Name of Parent/Guardian if minor

Spouse Name                                          Alternate Phone #

Pharmacy & location

Primary Insurance Name

Address                                                              Phone

Certificate #                                                        Group #

Subscriber Name

Primary Insurance Name

Address                                                              Phone

Certificate #                                                        Group #

Subscriber Name

I authorize Mt. Ascutney Hospital to release my medical records to my Ins Co. I authorize Ins Co to make
payment directly to Mt. Ascutney Hospital. I understand that it is my responsibility to contact my primary
physician for any referrals that are necessary. I will be financially responsible for any balance due if I fail
to get the appropriate referrals. I will also be responsible for any deductible and/or co-pay amount not
paid by my insurance company.

Signature                                                            Date
We are required by Federal HIPAA regulations to ask you how you would like to be called from the
waiting room:

By Name:                                          Tapped on shoulder

Motioned to:

May we contact you by (check all that apply):

Home Phone               Work Phone                Leave message with family member

Leave message on voicemail at work                 Leave message on home answering machine

Drug Store most used to fill prescriptions:

Town:                                         Phone:

Primary Care Physician:

Town:                                         Phone:

Worker’s Compensation Information:

Employer Name:                                            Phone #:


Date last worked:                                         Job Title:

W/C Insurance Carrier:                                    Phone #:


Claim #:                                                  Date of Injury:

Case Manager:                                             Phone #:
                                       Work History

Were you employed when your problem began?                          Yes         No

Have you filed a report of injury for this problem?                 Yes         No

Length of time at current employer

Have you missed work as a result of this problem?             Yes          No

Job Title                                 Date Last Worked

Maximum weight to lift/carry in your position

If this is a worker’s compensation claim, please complete the section below:


Workers Comp Insurance Name

Address                                                Phone #

Case Manager/Adjuster Name

Date of Accident:                          Claim #
                                    Current Symptoms

What condition are you being seen for today?

Which is your dominant hand?                     Left                  Right

Have you been treated for this condition before?

If yes, by whom?

When did the symptoms start?

Please check all of the following that you have had for this injury:

       X-rays               Date                         Location

       CT scan              Date                         Location

       MRI                  Date                         Location

       EMG’s                Date                         Location

       Vascular Studies     Date                         Location

Please state how this injury or condition occurred:

What is your greatest concern regarding this condition?

Do you smoke tobacco?              Yes           No      How much

Do you drink alcohol?              Yes           No      How much

Do you drink coffee/soda?          Yes           No      How much

Do you use illegal drugs?          Yes           No      How much

Have you ever seen a pain specialist?                                  Yes     No

Have you ever seen a rheumatologist?                                   Yes     No

Have you ever seen a Neurologist?                                      Yes     No

Have you ever seen another Orthopaedist for this problem?              Yes     No
                                      Medical History


Please list all medications or other things to which you are allergic


Please list all medications including over the counter items, which you are currently

Medication                         Dosage                      Frequency

Check below if you currently have or have ever had any of the following:

____ Joint Swelling                       ____ Nosebleeds
____ Tendonitis                           ____ Difficulty Swallowing
     Joint Laxity                         ____ Snoring
____ Decreased Range of Motion            ____ Shortness of Breath
____ Neck pain                            ____ Night Sweats
     Back Pain                            ____ Chest Pain
____ Snapping or locking                  ____ Ankle Edema
____ Rash                                 ____ Unintentional Weight Loss
     Loss of sensation                    ____ Constipation
____ Prior injury to area                 ____ Incontinence
____ Cold Sensitivity                     ____ Memory Loss
     Dry eyes or mouth                    ____ Blackouts
____ Change in vision                     ____ Falls
____ Decreased hearing                    ____ Insomnia
____ Other:

Please list all surgical procedures you have had:


Please check all that you have been diagnosed with or a direct family member has been
diagnosed with. If a family member please write the relationship to you on the line

              Ankylosing Spondylitis
              Autoimmune Disease
              Lyme Disease
              Rheumatoid Arthritis

Congenital or Inherited Abnormality of Hand or Extremity:

Please check any of the following that you have or have had:

       Abnormal Heart Rate                GERD                    Polio
       A-fib                              GI Bleed                Seizures
       Alcoholism                         Headaches               Sinus Infection
       Angina                             Heart Attack            Skin Disorder
       Anxiety                            Hepatitis               Sleep Apnea
       Bipolar                            Hypertension            Stroke
       Bursitis                           IBS                     Tendonitis
       Colitis                            Latex Allergy           Thyroid Disease
       Crohn’s Disease                    Liver Disease           Tuberculosis
       Depression                         Migraines               Ulcer
       Diarrhea                           MRSA                    Urinary Tract Infection
       Diabetes                           Osteoporosis
       Drug Addiction *(specify what)
       Cancer * Specify type and date
       Fractures* (please list type and date)

To top