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					                                 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!!

				
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