New Patient Form | Optimotion Orthopaedics | Joint Replacement Orlando, FL

Patient Intake - Knee

Referred by:*
Friend Family Social Media (Facebook, Google, Twitter) Seminar Emergency Room Billboard Doctor
PATIENT INFORMATION
First Name:*
Middle Name:
Last Name:*
DOB:*
SSN:
Gender:*
Male Female
Race:
Ethnicity:
Marital Status:*
Single Married Widow Divorced
Spoken Languages:*
Address/City/State/Zip:*
Cell Phone:*
Home Phone:
Email:*
Occupation:
Employer/Phone Number:
PRIMARY CARE DOCTOR
Physician Name:
Phone:
Fax:
Address/City/State/Zip:
Same as referring doctor listed above:
EMERGENCY CONTACT
Contact Name: *
Relationship to Patient: *
Cell Phone: *
Home Phone:
Work Phone:
Email Address:
CONSENT TO EXAMINATION AND TREATMENT
INSURANCE ASSIGNMENT AND RECORDS AUTHORIZATION
I am, hereby consent to examination and treatment as deemed necessary by and its physicians. I Hereby authorize Optimotion Orthopaedics to furnish patient health information concerning my relevant medical history (including but not limited to the super confidential information listed above) to any of the following: Other healthcare providers involved in my care, insurance carriers, attorneys and adjustors. I hereby assign to Optimotion Orthopaedics all payments for Medical Services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance.
INFORMED CONSENT FOR TELEMEDICINE SERVICES
I understand that telemedicine is the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to [name of provider] providing health care services to me via telemedicine. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. As always, your insurance carrier will have access to your medical records for quality review/audit. I understand that I will be responsible for any copayments or coinsurances that apply to my telemedicine visit. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting Optimotion Orthopaedics at . As long as this consent is in force (has not been revoked) Optimotion Orthopaedics may provider health care services to me via telemedicine without the need for me to sign another consent form.
Signature:*
Signature of:
Patient Parent/Guardian
Date:*
PATIENT RELEASE
I am, hereby authorize Optimotion Orthopaedics to release any or all of my patient health information including super confidential information to the person(s) listed below. (Example: A Spouse or relative may be involved in billing and insurance inquires or medication refills.)
Signature: *
Date:

Name
Relationship to Patient
Phone

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PRIVACY NOTICE
Inspect and Copy Your Protected Health Information (PHI): You have the right to inspect and copy your protected health information that may be used to make decisions about your care, with the exception of psychotherapy notes. If you want to see or copy your medical information, you must submit your request in writing to the Privacy Site Coordinator or to the Optimotion Orthopaedics Privacy Officer. If you request copies of information, the cost will be $1.00 per page for the first 25 pages then .25 per page after. You may also access your patient records through your patient portal free of charge.

In accordance with Health Information Portability and Accountability Act (HIPPA), patients of Optimotion Orthopaedics are entitled to and afforded the rights to privacy regarding their health related information as set forth under applicable law. Optimotion Orthopaedics will strive to ensure that patient information is used only for purposes authorized by the patient and as otherwise required by law. Upon request we can provide you with a complete copy of our Privacy Policies. Additionally, Patients have a right to review their medical records and furnish comments to their records during normal business hours, upon providing reasonable advance notice. Please review our complete Notice of Privacy Practices on our website or at our clinic locations.
CANCELLATION POLICY
If unable to keep your appointment, kindly give 24-hour notice to avoid $25.00 no-show charge.

Copays, deductibles, and coinsurance will be collected prior to treatment. If payment is not received at the time services are rendered the patient will receive 3 statements in regards to an outstanding balance. If your account is still delinquent, your account will be sent to collections.
Signature: *
Date:*
Patient Name:*
DOB:*
BODY PART #1
Chief Complaint
Body Part:*
Laterality:*
Left Right
Current pain level:* (No pain 0 - 10 Severe pain)
When did this condition start?*
Have you ever tried any of the following conservative treatment options?
1. Anti-inflammatory medications such as:* Aspirin Ibuprofen Naproxen Indomethacin Meloxicam Celecoxib Diclofenac Other
if Other
Dates/Duration Less than 3 months More than 3 months N/A
2. Physical Therapy:* At least 6 weeks 3 months More than 3 months N/A
Date of Injury or onset of pain:
3. Assistive devices:* Cane Walker Crutches Wheelchair N/A
Duration:
4. Knee brace:* Yes No
Duration:
5. Injections:* Cortisone Gel/Synvisc N/A How many injections:
Date of last inj:
6. Exercise program:* Yes No
Duration:
7 . Weight Loss:* Yes No
Duration:
Have you ever consulted any other physician regarding this condition?*
Yes No
Date(s)
Doctors Name & Contact Info
Recommended Treatment by this Doctor:
Have you ever undergone surgery on this body part?
1. Arthroscopic (scope surgery):* Yes No
Date(s):
Surgeons Name & Contact Info:
2. Joint Replacement Component/Prosthesis:* Yes No
(If known):
Date(s):
Surgeons Name & Contact Info:
3. Other Surgery:* Yes No
(If known):
Date(s):
Surgeons Name & Contact Info:
If Yes, please send the OPERATIVE REPORT to our office as soon as possible before the date of your appointment. If unable to submit beforehand, please bring the report with you.
Failure to bring in your medical records may delay your course of treatment.
Are you being a second body part?
Yes No

FALL RISK ASSESSMENT
Patient Name:*
Date of Birth:*
1. Do you use an assisted device?*(walker, cane or crutches) Yes No
2. Have you fallen within the past year?* Yes No
3. Do you feel a buckling sensation?* Yes No
4. Are you wheelchair or home bound?* Yes No
Patient Signature:*
Date:*
CURRENT MEDICATION LIST & ALLERGIES
Patient Name:*
Email:*
Date of Birth:
Height:*
Weight:*

List any Medication Allergies
Reaction
Severity (none, mild, moderate, severe)

No Known Allergies

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Are you a tobacco user?* Yes No
LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: Prescription and over the counter medications, herbals, vitamin/mineral/dietary supplement. ALL FIELDS ARE REQUIRED *
No Current Medication

Name of Current Medication (example: Aspirin tablet)
Dosage (example: 325 mg)
Frequency/Route of Administration (example: 3 times daily orally)
Length of Use

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PHARMACY INFORMATION
Please indicate the pharmacy your woud like your mediciations sent to:
Pharmacy Name:*
Pharmacy Telephone Number:*
Pharmacy Address:*
Patient Name:
Date:
Medical disorders*
If you have had any of the following, Place Mark inside boxes: No Medical History Stroke Sleep Apnea AIDS/HIV Cancer Breast Gout Alcoholism Cancer Colon Heart Attack Alzheimer’s Cancer Lung High Blood Pressure Anemia Cancer Prostate Hepatitis Rheumatoid Arthritis COPD Kidney Disease Asthma Depression Osteoarthritis Blood Clot Leg Diabetes Seizures Blood Clot Lung Drug Abuse Ulcers, Bleeding Blood thinners (Coumadin, Plavix, aspirin, etc) Other Disease (list below)
Surgical History*
If you have had any of the following, Place Mark inside boxes:* No Surgical History Reported Cardiac (Heart) Carpal Tunnel Left Wrist Carpal Tunnel Right Wrist Arthroscopy Left Elbow Arthroscopy Right Elbow Arthroscopy Left Shoulder Arthroscopy Right Shoulder Arthroscopy Left Ankle Arthroscopy Right Ankle Arthroscopy Left Knee Arthroscopy Right Knee Arthroscopy Left Hip Arthroscopy Right Hip Left Hip Replacement Right Hip Replacement Left Knee Replacement Right Knee Replacement Spinal Fusion Laminectomy Fracture Surgery Other Surgery (list in the box below)
Family History*
If any family Member below has any of the following history, Place Mark inside Circles
No Family Medical History
Father Medical History AIDS/HIV Diabetes Kidney Disease Anemia Gout Liver Disease Blood Clots Heart Attack Muscle Disease Cancer Hemophilia Osteoporosis Coronary Artery Disease Hypertension Rheumatoid Arthritis Osteoarthritis

Mother Medical History AIDS/HIV Diabetes Kidney Disease Anemia Gout Liver Disease Blood Clots Heart Attack Muscle Disease Cancer Hemophilia Osteoporosis Coronary Artery Disease Hypertension Rheumatoid Arthritis Osteoarthritis

Sibling Medical History AIDS/HIV Diabetes Kidney Disease Anemia Gout Liver Disease Blood Clots Heart Attack Muscle Disease Cancer Hemophilia Osteoporosis Coronary Artery Disease Hypertension Rheumatoid Arthritis Osteoarthritis
Review of Systems
If you have any of the following, please place mark inside boxes
Constitutional Weight Loss/Gain Weakness Fatigue Fever
Cardiovascular High Blood Pressure Chest Pain Rheumatic Fever Palpitations Has Pacemaker
Musculoskeletal Joint Pain Arthritis Muscular Weakness Stiffness Muscular Pain
Eyes Glasses or Contacts Blurred Vision Glaucoma Cataracts Excessive Tearing
Skin Rashes Sores Lumps Dryness Itching
Blood or Lymph Anemia Easy Bruising Easy Bleeding Swollen Glands
Ear Nose Mouth Throat Ears Ringing Earaches Hearing Aid Frequent Colds Nasal Discharge Hay Fever Nosebleeds Dentures Bleeding Gums Frequent Sore throats
Neurological Headache Dizziness Seizures Loss of Sensation Vertigo
Gastrointestinal Heart Burn Rectal Bleeding Abdominal Pain Gallbladder trouble Hepatitis
Respiratory Shortness of Breath Cough Wheezing Asthma Bronchitis
Genitourinary Blood in Urine Urinary Infections Kidney Stones Burning Urination Sexual Disease
Endocrine Thyroid Trouble Excessive Sweating Excessive thirst
Immunologic Reactions to Drugs Skin Rashes Reactions to Foods
Psychological Nervousness Depression Mood Changes
Social History: Please respond to the following by Placing Mark inside boxes
Substance Use
Do you
Use Tobacco?* Yes No Former
Use Alcohol?* Yes No
Use Caffeine?* Yes No
Use Illicit Drugs?* Yes No
Hand Dominance?* Right Handed Left Handed
Females Only
Could you be pregnant? Yes No
Allergies
Do you have allergies to any of the following medications or substances No Known Allergies Codeines Penicillin Sulpha Drugs Iodine / Shellfish Vantin Ampicillin Depakene Amoxil Aspirin Keflex Ceftin Cefzil Suprax Septra Lamictal Tegretol Bactrim Pediazole Dilantin Novacaine Insulin Lidocaine
Other Allergies Latex IVP/X-Ray Dye Metal Egg/Avian (Bird)
List any other allergies in this box:
* We care about your privacy. By checking this box you confirm that you have read and understood our privacy policy and consent to provide your personal information to us