SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
*Please have paperwork completed by your appointment time and bring diagnostic films to review*
Patient Name: _________________________________________Date: ______/_______/_______
Address:________________________________City_______________State____Zip_________
Sex: FemaleMale
Marital Status:
Single Married
Widowed Divorced
Social Security #:________________________________Date of Birth: ______/_______/_______
Phone #’s: Home: (____)____________Work: (____)____________ Cell: (____)____________
Occupation (if student please indicate):______________________________________________
Employer:_____________________________Address:_________________________________
Nearest Relative in Case of Emergency______________________________________________
(Name)
(Phone)
(Relationship)
Insurance Information
(Please complete guarantor information if parent or spouse is responsible for patient.)
Insurance Company (Primary):_____________________________________________________
Group #:____________________________Policy #:___________________________________
Insurance Company (Secondary):___________________________________________________
Group #:____________________________Policy #:___________________________________
Guarantor Name:________________________ Social Security Number:___________________
Phone #’s: Home: (____)___________Work: (____)_____________Cell: (____)____________
Occupation: ___________________________ Insured Date of Birth: ______/_______/_______
Employer:_____________________________Address:_________________________________
Workers Compensation
Did this result from an accident at work? Yes No Date of Injury:______/_______/_______
If yes, give the employer’s name and where injury occurred:_____________________________
If you have an Attorney their name:_________________________________________________
24-Hour Cancellation Notice is Required,
Otherwise You Will Receive a No Show Charge of $50.00
1
Release of Benefits and Information
I authorize my insurance benefits to be paid directly to the doctor. I am financially responsible
for any balance due. I authorize the doctor or insurance company to release any information
required for this claim.
Signed (X): __________________________________________Date:______/_______/_______
I authorize and give consent to Dr. Hollis to evaluate and treat, which may include x-rays.
Signed (X): __________________________________________Date:______/_______/_______
Non-covered Services: I understand that most insurance contracts DO NOT COVER DME
PRODUCTS AND SUPPLIES AND INJECTIONS, I AGREE TO ACCEPT
RESPONSIBILITY FOR THESE CHARGES SHOULD THEY OCCUR.
Signed (X): __________________________________________Date:______/_______/_______
I acknowledge that I have received a copy of Sound Orthopaedics & Foot and Ankle Center,
P.A. Notice of Privacy Practices with the effective Date of April 14, 2003 and have a full
understanding of the contents.
Signed (X): __________________________________________Date:______/_______/_______
I acknowledge that it is my responsibility to pay al balances on my account within 30 days of
notice. If for any reason I do not pay this, and the account is turned over to collections, I will be
responsible for collection fees that may be added to my delinquent account.
Signed (X): __________________________________________Date:______/_______/_______
2
SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
Patient Name________________________________________________________Age:______________
Referring Physician / Person:_____________________________________________________________
Primary Care Physician:_________________________________________________________________
Who else have you seen for this problem?___________________________________________________
CHIEF COMPLAINT:
Please state your main problem:___________________________________________________________
Please describe your problem in detail:_____________________________________________________
Date of onset:________________ How long have your symptoms been present?____________________
INJURY AND ACCIDENT INFORMATION:
Please describe the mechanism of injury:____________________________________________________
On the job injury (please describe): ________________________________________________________
Are you still working? Yes No
Do you like your job? Yes No
Have you missed work Yes No If Yes, how much time?________Last date worked____/____/____
Have your symptoms changed since your initial injury Yes No If Yes, Describe:_________________
Motor Vehicle Accident (please describe):___________________________________________________
HISTORY OF PRESENT ILLNESS:
Which hand / wrist is bothering you the most: Right Left
How severe is the problem? Mild Moderate Severe Disabling
Are you  right  left hand dominant?
How bad is your pain (please circle)?
No Pain
1
2
3
4
5
6
7
8
9
Worst Pain
Mark the area on your body where you feel the described sensations.
Numbness ///// Burning XXXXX Stabbing OOOOO Pins & Needles --------
PALM
BACK
BACK
FRONT
Physician/PA__________________________________________________ Date___________________
3
SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
HISTORY OF PRESENT ILLNESS (CONT):
Describe your pain (burn, ache, sharp, etc)___________________________________________________
How often do you have pain? (intermittent, constant)__________________________________________
When does the pain occur (night, with motion, at rest, etc)?_____________________________________
Does your pain radiate into other areas? Yes No
If Yes, Describe__________________________
What makes it better? __________________________What makes it worse?_______________________
Do you have swelling? Yes No
Did you have swelling within 2 hours of injury Yes No
Do you have locking (cannot straighten finger / wrist)? Yes No Describe:______________________
Do you have weakness / history of dropping things? Yes No If Yes, Describe___________________
Do you have instability / history of dislocations? Yes No
If Yes, How Often_________________
Do you have catching or popping sensations? Yes No
If Yes, Describe:___________________
Do you have numbness / tingling? Yes No
If Yes, Describe__________________________
Have you had prior injury / problems with this foot/ankle? Yes No
If Yes, Describe_____________
TREATMENT INFORMATION:
What prior treatments have you had (i.e. physical therapist, chiropractor, massage therapist, etc)?
Please list and describe.
1.
Treatment
Name of Prescribing Doctor
Location
Date Improved/Unchanged
______________________________________________________________________________
2.
______________________________________________________________________________
3.
______________________________________________________________________________
4.
______________________________________________________________________________
Have you had any diagnostic tests? Yes No If so please list:
Name of Prescribing Doctor
Location of test
Date of test
Results
MRI_________________________________________________________________________________
Bone Scan____________________________________________________________________________
Electrical Studies______________________________________________________________________
EMG/NCV___________________________________________________________________________
X-Rays______________________________________________________________________________
CT Scan_____________________________________________________________________________
Other________________________________________________________________________________
Physician/PA______________________________________________ Date_______________________
4
SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
REVIEW OF SYSTEMS:
Please describe any problems with head, eyes, ears, throat (i.e. sore throat, headache)
_____________________________________________________________________________________
Please describe any problems with your gastrointestinal system: (i.e. nausea, vomiting, diarrhea)
_____________________________________________________________________________________
Please describe any problems with your musculoskeletal & neurologic system (i.e. weakness, numbness)
_____________________________________________________________________________________
Please describe any problems with your genitourinary system (i.e. urinary / fecal incontinence)
_____________________________________________________________________________________
Please describe any problems with your pulmonary system (i.e. cough, shortness of breath)
_____________________________________________________________________________________
Please describe any problems with your cardiovascular (i.e. palpitations, chest pain)
_____________________________________________________________________________________
PAST MEDICAL HISTORY: Please list all medical problems.
 Anemia
 Heart Disease
 Stroke
 AIDS/HIV/STD
 Skin Disease
 Thyroid Disease
 Asthma/COPD
 Hepatitis
 Tumor (benign)
 Arthritis
 High Cholesterol
 Tumor (malignant)
 Bleeding Problems
 Osteoporosis
 Ulcers
 Diabetes
 Parkinson’s
 None of the above
 High Blood Pressure
 Seizure Disorder
 Other
Please list details or comments regarding above checked disorders:
_____________________________________________________________________________________
PAST SURGICAL HISTORY: Please list all previous operations and hospitalizations.
TYPE
YEAR
REASON
1.
______________________________________________________________________________
2.
______________________________________________________________________________
3.
______________________________________________________________________________
4.
______________________________________________________________________________
FAMILY HISTORY: Please list any disorders in immediate family members.
1.
______________________________________________________________________________
2.
______________________________________________________________________________
SOCIAL HISTORY:
Do you exercise regularly? Yes No
Type and amount per week_________________
Occupation:____________________________ Education / Last Grade Completed:__________________
Please check if applicable: Married Single Divorced Retired Pregnant # of Children _______
Physician/PA______________________________________________ Date_______________________
5
SOUND ORTHOPAEDICS FOOT & ANKLE CENTER P.A.
8418 East Bay Blvd Navarre, Florida 32566 Phone: 850-939-5275 Fax: 850-939-4152
MEDICATIONS: Please list all drugs including aspirin, laxatives, vitamins, herbs, and supplements.
DRUG NAME
DOSE
FREQUENCY
1.
______________________________________________________________________________
2.
______________________________________________________________________________
3.
______________________________________________________________________________
4.
______________________________________________________________________________
Do you smoke? Yes No Number of packs______ How many years?______ Quit When?______
Do you use tobacco? Yes No Number of tin_______ How many years?______ Quit When?______
Do you drink alcohol? Yes No Type and number of drinks/week/month?_____________________
Do you use drugs that are not medical? Yes No Type_____________________________________
Are you taking any pain medications? Yes No Type_____________________________________
ALLERGIES (including drug, latex, or other substance): Yes No
Please list drug name and reaction (i.e. rash, difficulty breathing, etc)
_____________________________________________________________________________________
FOR OFFICE USE ONLY:
Weight ___________Height ___________Pulse ___________SW5.07___________
Girth Measurements:
L
R
Calf
_______
_______
Thigh
________
________
Arm
_______
_______
Forearm
_________
_________
I. Head/Neck II. Spine/ribs/pelvis
III.RUE
IV.LUE
V.RLE
VI.LLE Gait
Inspection/Palpation:
alignment
symmetry
crepitation
effusion
tenderness
defects
masses
Stability:
laxity
subluxation
dislocation
Strength/tone: atrophy
flaccid
spasticity
Skin:
induration
erythema
nodules
rash
lesions
ulcers
Neuro:
sensation
touch
pin
vibration
DTR/babinski
Lymphatic(2 areas):
neck
axillae
groin
other
Psychiatric: mental status orientation (time, place, person)
mood/affect (depression, anxiety, agitation)
Cardiovascular: PVDZ
swelling
varicosities
temp
tenderness
edema
Physician/PA______________________________________________ Date_______________________
6