Accessibility Tools

Patient Intake Form Knee

  • Patient Intake - Knee
  • Friend Family Social Media (Facebook, Google, Twitter) Seminar Emergency Room Billboard Others Doctor
  • PATIENT INFORMATION

  • Male Female Other
  • Single Married Widow Divorced
  • PRIMARY CARE DOCTOR

  • Yes No
  • PHARMACY INFORMATION

  • Please indicate the pharmacy your woud like your mediciations sent to:

  • EMERGENCY CONTACT

  • PRIMARY INSURANCE INFORMATION

  • SECONDARY INSURANCE INFORMATION

  • FINANCIAL RESPONSIBILITY

  • Patient Spouse Parent Guardian
  • 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 As long as this consent is in force (has not been revoked) Optimotion Orthopaedics may provider health care services to me via telemedicine without the need for me to sign another consent form.

  • Patient Parent/Guardian
  • 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.)

    • Name
    • Relationship to Patient
    • Phone
  • 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.

  • KNEE INTAKE FORM

  • Chief Complaint

  • Left Right Both
  • Have you EVER tried any prior conservative treatment?

  • Yes No Other
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • * Please bring in the office notes from the orthopedic doctor if seen in the past year

  • Yes No
  • Yes No
  • Yes No
  • * If you had a knee surgery within the past seven years, please obtain the operative report and send to our office before your appointment

  • SURGERY DEPOSIT CONSENT

  • Dear Sir/Madam,

    Please make a surgery deposit of $200.00 at the front desk to facilitate scheduling of your surgery. If you have a surgery fee, this deposit will be applied towards it. Otherwise, the deposit will be refunded after surgery has taken place and we have received insurance payment for the surgery. PAYMENT IS ACCEPTED BY DEBIT/CREDIT CARD, CHECK OR CASH. This deposit is waived if you are an established patient scheduling your 2nd surgery with us.

    After making the surgery deposit, you will receive the following:

    1. 1. PowerPoint presentation: Please pay attention as it contains important information regarding your surgery. Following this, our surgery coordinator will assist you in scheduling your surgery date and address all concerns.
    2. 2. Surgery packet: It is extremely important that you read the entire packet and save it for reference. Please follow all the pre- and post-operative instructions mentioned in the surgery packet strictly.

    If you want your surgery to be moved to an earlier date, please inform our surgical coordinator to place you on the surgery cancellation list. We will contact you if there is an available slot.

    Surgery cancellation/postponing policy:

    1. 1. If you want to cancel/postpone your surgery, our office needs to receive the notice more than 30 days prior to your scheduled surgery date by certified mail or fax. Your surgery deposit will be fully refunded in this case.
    2. 2. Your surgery deposit will not be refunded if you cancel/postpone your surgery within 30 days of the surgery date for a non-medical reason.
  • Optimotion Orthopaedics

  • FALL RISK ASSESSMENT

  • 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
  • CURRENT MEDICATION LIST & ALLERGIES

    • List any Medication Allergies
    • Reaction
    • Severity (none, mild, moderate, severe)
  • LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING: Prescription and over the counter medications, herbals, vitamin/mineral/dietary supplement. ALL FIELDS ARE REQUIRED

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

  • 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)
  • MEDICAL RECORD RELEASE FORM

  • Authorization for Exchange of Confidential Information

  • I am, hereby authorize Optimotion Orthopaedics to (check one) release / obtain all medical, psychiatric, alcohol and/or drug abuse, HIV testing, ARC and/or AIDS diagnosis and information to/ from:

  • Continued Medical Care Second Opinion Insurance Attorney Personal
  • For Release Only: Are you transferring your total care to/from Optimotion Orthopaedics to/from the provider mentioned above: Yes/No

    I understand this consent is revocable upon written notice to Optimotion Orthopaedics, Steve Nguyen M.D., or Nam Dinh, M.D., except to the extent that the action by Optimotion Orthopaedics has already been taken on by this authorization. This authorization shall remain in force for a reasonable time to accomplish the purpose for which it is given, or will expire (in six (6) months).

    I hereby release Optimotion Orthopaedics, and its employees, agents, officers and affiliates, from any and all legal liability, responsibility, claim and damage that may arise from the release of information as requested.

    Alcohol and drug abuse information, if present has been disclosed from records whose confidentiality is protected by Federal Law. Federal regulation (42CFR, part 2) prohibits making any further disclosure of the information without the specific written authorization of the undersigned, or as otherwise permitted by such regulations.

    Notice to Requesting Party: There will be cost associated with this request. Your signature on this form indicates your knowledge of the fee. The medical records will be provided after the fee is paid.

  • * 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