Medical Director: Kedar K. Deshpande, M.D., FAAPMR
C. DeWayne Brinkman, P.A.
Psychology Services: Vijay Balraj, PhD
Interventional Spine Specialist
Interventional Pain Management
Physical Medicine & Rehabilitation
Your appointment with:
 Kedar Deshpande, M.D
___________________
Day
___________________________
Month
__________
Date
__________________
Time
Please bring the following documents with you:




Insurance card, driver’s license and co-payment
MRI films/CD, X-Rays, and/or CT Scans.
Please mail or fax your new patient history forms prior to appointment. Fax to Attn: Referral Coordinator @ 614468-0208. Your appointment may be delayed if packet is not completed.
Please arrive 15 minutes early to your appointment.
*New patients will not be issued a prescription on their initial consultation*


If the patient is unable to pay their co-pay at the time of visit, we reserve the right to reschedule the appointment.
Orthopaedic and Spine Center, LLC requires a 24 hour notification of cancellations. The office reserves the right to
dismiss a patient for two or more failure to notify the office of cancellations or no-show to appointments.
*Please mail or fax your new patient history forms prior to appointment.
Fax to Attn: Referral Coordinator @ 614-468-0208
Introduction to Orthopaedic and Spine Center
OSC offers an innovative and comprehensive approach for the treatment of acute and chronic pain. Pain is complex in
its causes and affects patients both physically and psychologically. Initially a thorough evaluation is performed on each
patient and correlated with physical exam findings and imaging studies to develop a treatment plan for acute conditions.
Depending on individual conditions this evaluation may include a physical therapy assessment, psychological assessment
and nutritional counseling to provide a comprehensive treatment plan for the patient.
Our Professional Staff
Kedar K Deshpande, M.D.
C. DeWayne Brinkman, P.A.
Vijay Balraj, PhD
Take a tour of our facility, interventional treatment demonstrations and details online.
www.oscpain.com
Orthopaedic & Spine Center, LLC
Kedar Deshpande, M.D., FAAPMR
C. DeWayne Brinkman, P.A.
Vijay Balraj, PhD
Interventional Pain Management
Physical Medicine & Rehabilitation
Physical Therapy
Psychological Services
1080 Polaris Parkway, Suite 200 Columbus, Ohio 43240
Phone: 614-468-0300
Fax: 614-468-0214
From The North
Take I-71 South to Exit 121 Gemini Place to Route 750
Polaris Parkway. Turn RIGHT off the exit. Second light
turn LEFT onto Polaris Parkway. First light turn LEFT onto
Capella Rd. Turn LEFT into the first entrance to 1080.
From The South
Take I-71 North to Exit 121 Polaris Parkway. Turn LEFT
off the exit. Continue west on Polaris Parkway. Turn
RIGHT at the fifth light onto Capella Rd. Turn LEFT into
the first entrance to 1080.
Orthopaedic & Spine Center – New Patient Demographics
Patient Information:
Patient Name: _____________________________________________________________________________________________
For Minor Only: Child lives with: Both Parents____ Mother ______ Father____ Other______________
Patient Address: __________________________________________________________________________________________
City:______________________________________________________________________ Zip:__________________________
Home Phone: __________________________ Work Phone: ___________________________Cell Phone: _____________________
Sex: M ___ F___ DOB: _____________ Age: ______________
Social Security #: ____________________________
Marital Status: S ______ M ______ D ______ W ______ Email Address: _______________________________________________
Preferred Language: _______________________________________
Race: American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander White
Ethnicity: Hispanic/Latino
Non-Hispanic/Non-Latino
Decline
Decline
Patient Employer: _______________________________________________ Occupation: ______________________________
Employment Status: Full Time
Part Time
Not Employed
Self Employed
Retired
May we leave a message at home with other residents? YES NO Answering Machine/Voicemail? YES NO
Emergency Contact: ___________________________________________________________
Same Household: Yes
No
Phone Number(s): ______________________________________ Relationship? ______________________________________
Insurance Information:
Primary Insurance: ___________________________________ Name of Policy Holder: ____________________________________
Policy #: ________________________________________________ Group#: ____________________________________________
Relationship to Policy Holder: ___________________________ Date of Birth of Policy Holder: _______________________________
Employer of Policy Holder: __________________________________ Still Employed?
YES
NO
Secondary Insurance: ________________________________ Name of Policy Holder: _____________________________________
Policy #: _________________________________________________ Group#: ________________________________________
Relationship to Policy Holder: ___________________________ Date of Birth of Policy Holder: _______________________________
Employer of Policy Holder: ___________________________________ Still Employed?
YES
NO
Third Insurance: ______________________________ (please give card to receptionist)
Is the reason for your visit today the result of:
Work Injury?
YES
NO Claim #: _____________________ Date of Injury: _____________________Claim Settled?:
Do you have any other active BWC claims?
Auto Accident? YES
NO
YES
Other Type of Accident/Injury?
In Litigation?:
YES
NO
NO
Claim#: ______________________________________________
Date of Accident: _________________ State Accident Occurred: ___________________
Who was at-fault? Patient
In Litigation?:
YES
YES
Other Party
NO
YES
NO
Auto Insurance Carrier: _______________________
Claim # _______________
Name of Attorney/Phone #: _________________________________________________
NO Date of Accident: ____________ Place of Accident: ____________________________
Name of Attorney/Phone #: _________________________________________________
Physician Information:
Referring Physician: ________________________________________________
Phone #: ________________________________
Primary Care Physician: ____________________________________________
Phone #: ________________________________
Patient Signature: ________________________________________________
Date: _________________________
******************************************************************************************
Medical History
Patient Name: ___________________________________________________________
Today’s Date: _______________________
Date of Birth: _______________________ Age: ___________ Height: ______ft ______in Weight: ________lbs Sex: ____________
Primary Care Physician: ____________________________________________________
Phone: ____________________________
Reason for today’s visit: ________________________________________________________________________________________
Date condition began: _______________________________ Was this the result of an accident or work injury? Yes _____ No _____
If so, please describe: __________________________________________________________________________________________
____________________________________________________________________________________________________________
Have you been treated previously for this condition? Yes _____ No _____ If yes, please describe treatment: ___________________
____________________________________________________________________________________________________________
Rate your pain with Medication (Please Circle)
0
1
2
3
4
5
6
7
8
No Pain
Rate your pain without Medication (Please Circle)
9
10
0
Worst Pain
1
2
3
4
5
6
7
8
9
No Pain
10
Worst Pain
Please check the words that BEST describe your pain:
 Constant
 Aching
 Burning
 Abnormal Skin
Sensitivity
 Shock-like
 Intermittent
 Stabbing
 Shooting
 Deep
Do you have numbness and/or tingling in your arms/legs? Yes _____ No _____ If yes, please explain: _________________________
____________________________________________________________________________________________________________
What makes your pain better? ___________________________________________________________________________________
What makes your pain worse? ___________________________________________________________________________________
Please check all previously or currently used methods of pain management:
 Acupuncture
 Medication
 Injections
 Herbal Medication
 Chiropractic
 Exercise
 Surgery
 Massage
 Homeopathy
 Biofeedback
 Hypnosis
Have you ever had Physical Therapy for this condition? Yes _____ No _____
If yes, when did you have Physical Therapy? _____________________________
 _____________________
How many visits? 1-6
Please check any of the following medications that you have tried to treat this condition:
 Ibuprofen (Advil, Motrin)
 Naproxen (Aleve,
Naprosysn)
 Celebrex
 Mobic
PREVIOUS IMAGING RELATED TO TODAY’S VISIT (Please list most recent first):
Date
Test Performed
Part of Body
Facility
7-12
>12
Patient Name: ________________________________________ Date of Birth: _____________________
CURRENT MEDICATIONS (Please include all prescription and over-the-counter medications):
Name/Dose
Name/Dose
1. ________________________________________________
6. _________________________________________________
2. ________________________________________________
7. _________________________________________________
3. ________________________________________________
8. _________________________________________________
4. ________________________________________________
9. _________________________________________________
5. ________________________________________________
10. ________________________________________________
Do you take any of the following blood thinners:
Yes No
  Excedrin,Bayer
Vitamin E
  Coumadin/Warfarin
Fish Oil, Shark Oil
  Heparin
Omega 3
  Plavix
Lovaza
No




Yes




Yes




Pletal
Effient
Aggrenox
Pradaxa
No
 Aspirin 81mg
 Aspirin 325mg
 Brilinta

Yes




No




Name/Phone # of the doctor prescribing any of the above blood thinners: _______________________________________________
Do you have a Pacemaker/Defibrillator? Yes _____ No _____ If yes, name of company: ____________________________________
Name of Cardiologist managing Pacemaker/Defibrillator: _________________________________________________________
YOUR PAST MEDICAL HISTORY (Please check all that apply):
 Anxiety
 Depression
 Heartburn
 Osteoarthritis
 Artificial Joint
 Diabetes
 High Blood Pressure
 Poor Circulation
 Asthma
 Epilepsy/Seizures
 Kidney Disease
 Rheumatoid Arthritis
 Bleeding Disorder
 Fibromyalgia
 Liver Disease
 RSD
 Claustrophobia
 Gout
 Lung Disease
 Sleep Apnea
 Colitis
 Headaches
 MRSA
 Thyroid Disorder
 Defibrillator (see above)
 Heart Disease
 Obesity
 Ulcer
 Stroke/TIA (Date of Last Episode: ____________________)
Other: ___________________________________________
ALLERGIES: List all allergies you have to medication, latex, IV dye, or shellfish and reaction: _________________________________
____________________________________________________________________________________________________________
PREVIOUS SURGERIES RELATED TO TODAY’S VISIT (Please list most recent first):
Year
Surgery
Do you smoke? Yes _____ No_____
Part of Body
How Often: DAILY or SOME DAYS
Physician
How Many Cigarettes: ________
Do you drink alcohol? Yes _____ No_____ Type of Alcohol? WINE BEER LIQUOR
How Often: _________________
Do you have or have you ever had a problem with substance abuse including prescription medication, street drugs or alcohol?
Yes _____ No _____ If yes, please explain: ____________________________________________________________________
Patient Name: ________________________________________ Date of Birth: _____________________
Family History
(Please mark a minimum of one box per relative. If additional space is need, use the bottom of this page)
Relative
N/A
Alive
Deceased
Unknown
Year
Of
Birth
Diabetes
Hypertension
Heart
Disease
Father
Daughter
Daughter
Daughter
Daughter
Son
Son
Son
Son
Mother
Paternal
Grandfather
Paternal
Grandmother
Maternal
Grandfather
Maternal
Grandmother
Sibling
Sibling
Sibling
Sibling
Sibling
Please list below for additional family members, diagnosis or information:
Stroke
Mental
Illness
Cancer
Unknown
Patient Name: ________________________________________ Date of Birth: _____________________
REVIEW OF SYSTEMS: Are you CURRENTLY experiencing any of these conditions/symptoms? (Please check all that apply)
 Fever
 Temperature Changes
 Migraines
 Shortness of Breath
 Chills
 Discoloration
 Difficulty Swallowing
 Chest Pain
 Weight Loss
 Sudden Loss of Bladder
Control
 Heart Murmur/Irreg. Rate
 Joint Swelling
 Anxiety
 Unusual Bruises
 Joint Pain
 Sudden Loss of Bowel
Control
 Rashes
 Weakness
 Hair Loss
 Numbness/Tingling
 Depression
 Other Mental Illness
 Excessive Bleeding
 Difficulty Sleeping
 Blood Clots
 _____________________
If you circled any of the above: Are you currently seeking treatment for the condition(s)? Yes _____ No _____
If yes, name/phone # of physician: _______________________________________________________________________________
WORK STATUS: What is your current work status? Please check:

Retired

Temporary Total (TTC/C-84)

Part-Time with Restrictions

Full-Time with Restrictions

Unemployed

Short-Term Disability



Permanent Disability (SSI)

Long-Term Disability
Part-Time without
Restrictions
Full-Time without
Restrictions
If you are off work, who has taken you off work? ____________________________________________________________________
When are you scheduled to return to work? ________________________________________________________________________
If you are working with restrictions, what are your restrictions? ________________________________________________________
Which physician is writing these restrictions for you? ________________________________________________________________
PHARMACY INFORMATION:
Name: _________________________________________________ Phone: _____________________________________________
Address: ____________________________________________________________________________________________________
The information supplied is to the best of my knowledge. I understand that any falsification of information may compromise
medical treatment.
Patient Signature: ___________________________________________________________
Date: _________________________
Parent/Guardian Signature: ___________________________________________________
Date: _________________________
(if patient is a minor)
FOR PHYSICAL THERAPY PATIENTS ONLY:
If your primary insurance is Medicare, do you feel you would benefit from a referral to social services for housing assistance, bill
payment assistance, etc? Yes _____ No_____
Are you currently receiving home care services? (i.e. nursing, home health aide, physical therapy, occupational therapy, speech
therapy) Yes _____ No _____