Date:______________
Patient Name:
Patient SSN:
Birthdate:
Age:
Sex:
State:
Zip:
Patient
Mailing Address:
City:
Patient E-mail Address:
Home Phone/Cell #
Work #
Emergency Contact Name:
Phone #
Preferred Language:
Race:
Primary
Insurance
Patient
Employer
Spouse
Ethnicity:
Marital Status:
Married
Divorced
Spouse’s Name:
Spouse’s Birthdate:
Spouse’s SSN:
Spouse’s Employer:
Widowed
Employer of Patient/Responsible Party:
Employer Address:
City:
State:
Zip:
Name of Insurance Carrier:
Name of Insured as it appears on the card:
Relationship to Patient:
Effective Date:
Claims Mailing Address:
City:
Secondary
Insurance
Single
State:
Zip:
Name of Insurance Carrier:
Name of Insured as it appears on the card:
Relationship to Patient:
Effective Date:
Claims Mailing Address:
City:
State:
Zip:
History & Intake Form
Patient Name:
Date:
Please circle/Answer each question:
Patient Height:__________________________
Patient Weight:__________________________
Patient Occupation:_______________________________________________________________
Problem
Right knee
Left knee
History of
Present Illness
Left shoulder
Other:
Was this an injury?
If so, what is the date of the
injury?
Yes
No
Was this a work related injury?
Yes
No
Severity:
Quality: Is the
Pain/Problem
Timing: Is the
Pain/Problem
Associated
Signs/Symptoms:
Does anything make the
Pain/Problem
Better/worse?
What Treatment/Testing
have you had previously
for this Pain/Problem?
If not an Injury; how long
have you had this
Pain/Problem?
Do you know what
caused the
Pain/Problem?
Pharmacy
Right shoulder
0 1 2 3 4 5 6 7 8 9 10
Dull
Other:
Throbbing
Sharp
Constant
Intermittent
Numbness
Popping
Other:
Swelling
Locking
Clicking
Grinding
Yes
No
If Yes, Please Describe:
Better
Worse
Yes
No
If Yes, Please Describe:
Name of local Pharmacy:
Phone #
Pharmacy Address:
City:
State:
May we Import/Update your medication list from your Pharmacy?
Zip:
Yes
No
General
Information
Name of Primary Care Physician:
Address of Primary Care Physician:
City:
State:
Who told you about our office?
Physician
Other:
Zip
Friend
Family
Internet
History & Intake Form (Continued pg 2)
Past Medical History (Please check all that apply):
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Anemia, Chronic
Anxiety
Asthma
Atrial Fibrillation
Breast Cancer
Chronic Pain
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes, Insulin Dependent
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Diabetes, Non-Insulin Dependent
End Stage Renal Disease
GERD
Hepatitis
HIV/AIDS
High Cholesterol
Hyperparathyroidism
Hypertension
Hyperthyroidism
Hypothyroidism
Leukemia
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Lung Cancer
Lymphoma
Multiple Myeloma
Obesity, Morbid
Obesity
PBPH
Prostate Cancer
Radiation therapy
Seizures
Stroke
Other____________________
None
Past Surgical History (Please check all that apply):
☐
☐
☐
Appendix (Appendectomy)
☐
Breast: Lumpectomy
☐
☐
☐
☐
☐
☐
Colectomy: Diverticulitis
Bladder Removed
Breast: Mastectomy
☐ Right ☐ Left ☐ Both
☐ Right ☐ Left ☐ Both
Colectomy: IBD
Colon: Colostomy
Gallbladder Removal
Heart: Biological Valve Replacement
Heart: Coronary Artery Bypass
Surgery
☐ Heart Transplant
☐ Heart: Mechanical Valve Replacement
☐ Heart: PTCA
☐ Kidney Stone Removal
☐ Kidney Transplant
☐ Liver: Liver Transplant
☐ Liver: Shunt
☐ Ovaries Removed: Ovarian Cancer
☐ Ovaries: Tubal Ligation
☐ Pancreas: Pancreatectomy
☐ Prostate Removed: Prostate Cancer
☐ Prostate Removed: TURP
☐ Rectum: APR
☐ Rectum: Low Anterior Resection
☐ Skin: Basal Cell Carcinoma
☐ Skin: Melanoma
☐ Skin: Skin Biopsy
☐ Skin: Squamous Cell Carcinoma
☐ Hysterectomy: Caesarean
☐ Hysterectomy: Uterine Cancer
☐ Hysterectomy: Cervical Cancer
☐ Other__________________
☐ None
Past Orthopedic History (Please check all that apply):
☐ Ankle Fracture
☐ Ankylosing Spondylitis
☐ Bursitis
☐ DISH
☐ Epidural Injections, Spine
☐ Fracture
☐ HNP, Lumbar
☐ Metastatic Bone Disease
☐ Osteoarthritis
☐ Osteopenia
☐ Osteoporosis
☐ Primary Bone Sarcoma
☐ Scoliosis
☐ Spine Fracture
☐ Soft Tissue Sarcoma
☐ Spinal Stenosis, Cervical
☐ Spinal Stenosis, Lumbar
☐ Vertebral Body
☐ Gout
☐ Hip Fracture
☐ HNP, Cervical
☐ Psoriatic Arthritis
☐ Rheumatoid Arthritis
☐ Ricketts
☐ RSD
☐ Sciatica
☐ Vitamin D Deficiency
☐ Wrist Fracture
☐ Other__________________
☐ None
Compression Fracture
History & Intake Form (Continued pg 3)
Past Orthopedic Surgery (Please check all that apply):
☐ Ankle Fracture ORIF
☐ Joint Replacement: Knee
☐ Right ☐ Left ☐ Both
☐ Right ☐ Left ☐ Both
☐ Carpal Tunnel Decompression
☐ Joint Replacement: Shoulder
☐ Right ☐ Left ☐ Both
☐ Right ☐ Left ☐ Both
☐ Cervical Spine Surgery ACDF
☐ Cervical Spine Surgery: Disc Replacement
☐ Distal Radius ORIF
☐ Knee Arthroscopy
☐ Right ☐ Left ☐ Both
☐ Kyphoplasty/Vertebroplasty
☐ Lumbar Spine Surgery: Decompression
☐ Lumbar Spine Surgery:
☐ Right ☐ Left ☐ Both
☐
Intermedullary Nailing Femur
☐ Right ☐ Left ☐ Both
Decompression & Fusion
☐
Intermedullary Nailing Femur
☐ Right ☐ Left ☐ Both
☐
☐
Joint Replacement: Hip
☐
Lumbar Spine Surgery:
Disc Replacement
☐ Right ☐ Left ☐ Both
Rotator Cuff Repair
☐ Right ☐ Left ☐ Both
☐
☐
Other___________________________________
None
Medications: (Please list all your medications or check option that applies):
Dosage:
# times dosage taken per day
Medication
List
Name of Medication:
☐
Not currently taking any Medications
☐
I brought a copy of my Medication list (Please provide to front Desk)
Medication
Allergies
Allergies (Please list all known allergies or check the option that applies):
☐
Name of Medication:
No know Allergies to Medications
Please describe allergic reaction, severity, and Symptoms
☐
I brought a copy of my Allergy list (Please provide to front desk)
History & Intake Form (Continued pg 4)
Social History (Please Check all that Apply):
Cigarette Smoking:
Alcohol Use:
Exercise Frequency:
☐Never Smoked
☐Quit: Former smoker
☐Smokes less than daily
☐Smokes daily
☐Do not drink Alcohol
☐Less than 1 drink a day
☐1-2 Drinks a day
☐3 or more drink a day
☐Several times a day
☐Once a day
☐A few times a week
☐A few times a month
☐Never
☐Other___________________
# of packs per day___________________
Review of Systems
Please Circle any of the following symptoms you are currently experiencing:
Musculoskeletal:
Neurological:
Constitutional:
Integumentary:
Hematological/Lymphatic:
Allergic/Immunologic:
Cardiovascular:
Endocrine:
ENT/Mouth:
Eyes:
Gastrointestinal (G.I.):
Genitourinary (G.I.):
Respiratory:
Psychiatric:
joint pain, joint swelling, joint stiffness
numbness, tingling, dizziness, headaches, tremors
fatigue, weight change, fever, chills
poor healing wounds, redness, rash, itching
easy bleeding
immunosuppression
chest pain, palpitations
excessive thirst or urination
ringing in ears
corrective lenses, blurred vision
constipation, diarrhea
frequent urination, difficult/painful urination, incontinence
shortness of breath, wheezing cough
nervousness, anxiety, depression
Please check yes or no for the following:
Yes
No
Alerts
Blood Thinners
Pacemaker
Metal Allergy
Latex Allergy
Iodine/Shellfish Allergy
Adhesive Allergy
Under Pain Management
***Please inform the Physician, Medical Assistant, or Front desk Staff of any other medical
conditions or concerns.
Family History
Please inform us of your Family Members’ Medical History by checking the appropriate box:
Mother
Father
Sister
Brother
Hypertension
Osteoarthritis
Osteoporosis
Scoliosis
Diabetes
Other
☐ No Family History (Checking this box indicates no past Family Medical History)
Daughter
Son
Other
History & Intake Form (Continued pg 5)
Disclosure Statement
Based upon the Martin Knee and Sports Medicine Center P.A Compliance Plan
and the American Academy of Orthopedic Surgeons Code of Medical Ethics and Professionalism for Orthopedic Surgeons,
We require full disclosure by each of our physicians of any direct or indirect financial relationships that they may have with
entities where patients may be referred.
Those are listed below:
Arkansas Surgical Hospital and MRI: Dr. Ken Martin
Little Rock Surgery Center: Dr. Ken Martin
Pinnacle Cell Surgical Center LLC: Dr. Ken Martin
___________________________________________________________________________________________________
Acknowledgment of Receipt of Privacy Notice
I have received a copy of Martin Knee and Sports Medicine Center P.A.
Notice of Privacy Practices.
I hereby authorize release of information to the following parties:
______________________________________________________________________
I understand that all co-pays are due at the time of service.
I hereby request my insurance companies and/or Medicare to pay directly to Martin Knee and Sports Medicine Center P.A. any
proceeds payable under the terms of my policy and/or policies. I understand and agree any unpaid balance not covered by
this policy is my responsibility and will be paid in full by me. I also give my consent to Martin Knee and Sports Medicine
Center P.A. to release medical information to my insurance companies and/or Healthcare financing administration.
Printed Name of Patient:
Printed Name of Responsible party:
Relationship to Patient:
Signature
***If Patient is a minor, a responsible party must sign
Date: