IONS Institute for Orthopedic and Nerve Surgery 230 E Day Rd., Suite 130 Mishawaka, IN 46545 (574) 247-4667 PATIENT INFORMATION Name_______________________________________________Nickname__________________________ Last First Middle initial (if applicable) Social Security # ______-______-______ Date of Birth_____________ Age_______ Sex Male Female Address_____________________________________City_________________State_____ Zip__________ Phone Number_(_____)_____________________Cell_(_____)_________________Work_(_____)___________ Preferred Contact: Home Cell Work Are you a Student?: Yes No Marital Status: Married Single Divorced Separated Widowed Primary Language Spoken: English Spanish Other____________ Religion:___________________ Patient Employer:__________________________________Occupation:____________________________ Employer Address:______________________________City______________State______Zip__________ Family Physician:_______________________________ Who may we thank for referring you? Internet Insurance Co. Television Phone book Referring Physician (Name):____________________________ EmergencyRoom/Hospital (Name):__________________________ Other____________________ Emergency Contact______________________Phone_(____)____________Relationship_______________ PRIMARY INSURANCE/ADDITIONAL INSURANCE Name of Policy Holder__________________________________________Date of Birth_______________ Social Security #______-_____-_____ Relationship to Patient____________________________________ Address (if different from patients)__________________________City__________State______Zip______ Insurance Co.________________________________ID#_______________________Group#___________ Is patient covered by additional insurance? Yes No Name of Policy Holder__________________________________________Date of Birth_______________ Social Security #______-_____-_____ Relationship to Patient____________________________________ Address (if different from patients)__________________________City__________State______Zip______ Insurance Co.________________________________ID#_______________________Group#___________ Parent(s) /Guardian Information (If patient is a minor) Name_________________________________________________Relationship______________________ First Middle Last Address___________________________________City__________________Sate______Zip___________ Social Security #_______-______-______ Date of Birth ______/_______/_______ Workman’s Compensation/Liability Workman’s Comp/Liability Carrier_________________________________________________________ Billing Address______________________________City__________________State________Zip_______ Contact Person______________________________Claim #___________________Date of injury_______ Contact Phone #_(_____)______________________Contact Fax #_(____)__________________________ Notice to Our Patients As required by the HIPAA Privacy Regulations, all patients who received health care service in our office must: Receive the attached “Notice of Privacy Practices” form; and Sign the “Acknowledgement” form below. A complete list of this policy is available in our office at your request. Please note that the attached notices are not a consent form. This form must be read in full by the patient and signed before treatment can be provided; rather, the Notice provides each patient with a summary description of: How our office will use and disclose their medical information for legitimate business purposes. How each patient can exercise their rights with regard to this medical information. IN ORDER FOR US TO REMAIN HIPAA COMPLIANT PLEASE LIST ANY PERSON(S) OR COMPANIES THAT YOU GIVE YOUR PERMISSION TO OBTAIN WRITTEN OR VERBAL INFORMATION ON YOUR BEHALF: (YOU DO NOT HAVE TO LIST YOURSELF OR OTHER PHYSICIANS) _____________________________________________________________________________________________________ Name Relationship Phone Number _____________________________________________________________________________________________________ Name Relationship Phone Number IONS Policies and Procedures You must allow five to seven business days for completion of all forms. There will be a $5.00 charge per form. If you need the form filled out immediately there will be an additional $5.00 per form charge. Please allow 24 hours for medication refills to be called in. Medication refill requests must be made during business hours only. A charge of $20.00 will be assessed to your account for broken appointments unless 24 hours notice is given. This charge is not billable to insurance companies. Assignment and Release I certify that I, and/or my dependant(s) have insurance coverage with the above named insurance companies and assign directly to Dr. Akre all insurance if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance admissions. The above named doctor may use my health care information and may disclose such information to the above named Insurance Company (ies) and agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. I acknowledge that I have received a current copy of the Privacy Notice. I also acknowledge that I have read and understand all other policies and agree to the terms set above. _______________________________________________________________ ___________________________ Signature of patient/guardian/personal representative Date IONS Medical History Form Patient Name: _____________________________________________DOB:_ ___/____/____ Age: _______ Height: ________ Weight: ________ Primary Care Physician: _______________________ Referring Physician: _____________________ Pain Management:__________________ Allergies: (MEDICATION & ENVIRONMENTAL): ______________________________________________________________ ______________________________________________________________________________________ _____________________ Medications: (PLEASE LIST ALL CURRENT MEDICATIONS AND DOSAGES): ____________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ __________________________________________________________________ Chief Complaint: What problem are we seeing you for? _________________________________________ Date of Onset / Injury: ___/___/___ How did you get hurt? ________________________________________________________________________________________________ _____ Where did you get hurt? ________________________________________________________________________________________________ ____ Please rate your pain at its BEST on a scale of 0-10 (0=NO pain, 10=Extreme pain): 0 1 2 3 4 5 6 7 8 9 10 Please rate your pain at its WORST on a scale of 0-10 (0=NO pain, 10=Extreme pain): 0 1 2 3 4 5 6 7 8 9 10 Circle the word(s) that best describe your pain: Radiating Aching Burning Dull Piercing Sharp Throbbing Other_____________________ What makes your pain WORSE? Bending Stairs Lifting Movement Pushing Sitting Standing Walking Other:______________________________ What makes your pain BETTER? Brace Elevation Exercise Heat Ice Massage Meds Mobility Therapy Rest Stretching Other:_________________ Do you have any of the following: Bruising Crepitus DecreasedMovement DifficultySleeping Instability Limping Locking NightPain Numbness Popping Spasms Swelling Tingling Tenderness Weakness Review of Systems: Constitutional Cardiovascular Integumentary Metabolic/Endocrine □Good general health □Chest Pain/Angina □Itchy Skin □Cold Intolerant □Fatigue □Cyanosis □Rash □Hair loss □Fever □Irregular □Skin infections □Heat Intolerant □Night Sweats Heartbeat □Skin Lesions □ Other □Weight Gain □Leg Swelling □Other_________________ _____________________ □Weight Loss □Syncope □Other_- □Other_- ________________ ________________ HEENT Gastrointestinal Neurological Psychiatric □Headache □Abdominal Pain □Difficulty walking □Anxiety □Hearing Loss □Constipation □Dizziness □Depression □Vertigo (dizziness) □Diarrhea □Poor Coordination □Insomnia □Vision Loss/Glasses □Nausea/Vomiting □Paresthesia (numbness) □Other_____________________ /Contacts □Tremors □ Other □Other_________________ _______________ Respiratory Genitourinary Hematologic Immunological □ Cough □Dysuria (Painful) □ Blood Disorder □Enviromental Allergies □Dyspnea(shortness of □Frequent □Other_____________________ □Food Allergies breath) Urination □ Other □ Wheezing □Hematuria _____________________ □ Recent Infection (Blood) □ □Urge Incontinence Other______________ □Urinary Incontinence Please Fill Out The Back Side Of This Form Past Medical and Family History: (PLEASE CHECK ALL THAT APPLY) DIAGNOSIS SELF MOTHER FATHER SISTER BROTHER Alive and well Aids/HIV Alcoholism Allergies Alzheimer’s Disease Asthma/ Blood Disease COPD Cancer Stroke Depression Diabetes Heart Disease Hepatitis Hypertension Irritable Bowel Dis Migraines Obesity Osteoarthritis Osteoporosis Renal/Kidney Disease Seizure Disorder Other Other Past Surgical History: (PLEASE CHECK ALL THAT APPLY) Year: Year: Year: ACL Surgery Back Surgery Hernia Repair Angioplasty Coronary Art. Bypass L/R Hip Replacement Angio W/Stent Cardiac Valve Replacement L/R Knee Replacement Appendectomy Carpal Tunnel Release L/R Shoulder Replacement L/R Arthroscopy Cataract Extraction/ LASIK Laminectomy Ankle L/R Arthroscopy Cholecystectomy (Gallbladder) Meniscus Surgery Elbow L/R Arthroscopy Hip Colectomy Bowel Resection L/R Arthroscopy Colostomy ORIF Wrist L/R Arthroscopy Thyroidectomy Pacemaker Knee L/R Arthroscopy Gastric Bypass Tonsillectomy (Tonsils) Shoulder Other Surgeries: Social History: Occupation: __________________________________________ Special Diet: (e.g. low cal., low carb, diabetic) _______________________________________________ Tobacco Use? YES NO How Many Packs Per Day? _______Year Quit? ___________ Substance Abuse? YES NO Substance: _________________________________ Alcohol Consumption? YES NO How many drinks per week? ________________________ Patient Signature: ___________________________________________ Date: ______________ Physician Review: ______________________________________ Thank You For Taking The Time To Fill Out This Form!!