PLEASE COMPLETE IN INKToday’s Date: Patient Account #: PATIENT NAME: Referring Physician: Primary Care Physician: Other Treating Physicians: Athletic Trainer / School: (if a high school or collegiate athlete)

Date of Birth: Age: Height: Weight:

MEDICAL HISTORY: smelborP lacideM oN Peripheral Vascular Disease

DEXA Scan or Bone Density Scan Hiatal Hernia/Reflux Disease History of MRSA Peptic Ulcer Disease

Claustrophobic or fearful of enclosed spaces Diverticulitis gniriuqeR-nilusnI ,setebaiD Urinary Tract Infections nilusnI-noN ,setebaiD Kidney Stones r and/or Factor V, Factor VIII deficiencyedrosiD gnideelB High Cholesterol

Pulmonary Embolism (Blood Clot Lung) Osteoporosis Deep Vein Thrombosis (Blood Clot Leg) Fibromyalgia

Thyroid Disorder Seizure Disorder SDIA ro VIH Gout amohpmyL ro aimekueL Osteoarthritis tnalpsnarT nagrO Rheumatoid Disease kcattA traeH Migraine Headaches Coronary Artery Disease / Heart Disease Cancer (type) aimhtyhrrA traeH Hepatitis rekamecaP Liver Disease rumruM traeH Psoriasis or Other Skin Disease ekortsiniM ro ekortS Poliomyelitis erusserP doolB hgiH Psychiatric Disorder amhtsA Anxiety Disorder DPOC ro amesyhpmE Depression ainomuenP Drug Addiction sisolucrebuT

Malignant Hyperthermia Glaucoma Dialysis / Renal Failure Reflex Sympathetic Dystrophy (CRPS)

Please list any other conditions not mentioned above:

PAST SURGICAL HISTORY: Please list any operations you have had in the past & date or approximate age at time of procedure

Date or Age No Previous Surgery

Fracture without Surgery Fracture with Surgery Shoulder Surgery Hand Surgery

Spine Surgery

Foot/Ankle Surgery Knee Surgery

Total Hip Arthroplasty

Heart Related Surgery Total Knee Arthroplasty

ymotcedneppA

noitceS-C Gall Bladder

riapeR ainreH ymotceretsyH

Tonsillectomy/Adenoidectomy

Please list any additional surgeries:

egA ro etaD noitarepO

250 Cetronia Road • Allentown, PA 18104 • Phone: 610-973-6200 • www.oaaortho.comLehighton: 1241 Blakeslee Blvd. Dr. E. ● Lehighton, PA 18235 ● 570-386-9910

Bethlehem: 2901 Emrick Blvd. ● Bethlehem, PA 18020 ● 610-973-6200

FAMILY HISTORY: Do any of these diseases run in your immediate family - Mother (M) Father (F) Sister (S) Brother (B)? Mark box and indicate relationship. No Medical Conditions M F S B Heart Disease M F S B

Rheumatoid Arthritis M F S B

Asthma M F S B High Blood Pressure M F S B

Stroke M F S B

Back Problems M F S B Cancer M F S B Diabetes Insulin Dependent M F S B Diabetes Non-Insulin Dependent M F S B

Orthopaedic Problems M F S B

Other

Abused Prescription Drugs Used Recreational Drugs Used Anabolic Steroids Used Other Performance Enhancing Substances

SOCIAL HISTORY: Marital Status: Married Single Divorced Separated Widowed Domestic Partner Number of children?

Do you smoke? Yes No If yes, how many packs a day? If yes, age started

?dekoms ylsuoiverp tnuoma & tiuq uoy did nehw ,rekoms tsap a era uoy fI

Do you use chewing tobacco? Yes No ?sraey ynam woH ?sehcuop/snit ynam woh ,sey fI

Do you use alcohol? No Occasional Moderate

Heavy

Do you use caffeine? No Occasional Moderate

Heavy

Do you exercise? No Occasional Moderate

Heavy

Recreational Activities (sports, hunting, fishing, gardening hobbies, etc.)

Education Less than 8th Grade 8th Grade 9th Grade 10th Grade

11th Grade 12th Grade 2 Year College 4 Year College Post Graduate

OCCUPATIONAL HISTORY:

Employer: What is your primary occupation (if not working, what was your primary occupation)? How many years have you been with your current employer? If not working, how long has it been since you stopped?

What statement describes your current employment situation (check all that apply)? Retired (not due to health) Currently Working Unemployed Homemaker On Unpaid Leave On Paid Leave Disabled

Is there litigation in process pertaining to your symptoms? Yes No

MEDICATIONS:

None

Please list all medications or drugs including birth control pills, over-the-counter medications or herbal supplements you are currently taking

Drug or Medicine Amount/Dose Start Date Stop Date Stop Reason

ALLERGIES: Please list all medications, metals, dyes, latex or foods. If you have a paper list of your medications or allergies, we will make a photocopy of them.

Allergy List Reaction

No Known Drug Allergies

Date:

Patient Name: DOB:

REVIEW OF SYSTEMS: Have you had any of the following in the past six (6) months? Please circle all that apply.

CONSTITUTIONAL (General)Constitutional: fever, night sweats, weight gain (______lbs), weight loss (______ lbs), exercise intolerance

EYESEyes: dry eyes, irritation, vision change

ENMT (Ears, Nose, Mouth, Throat)Ears: difficulty hearing, ear pain Nose: frequent nosebleeds, nose/sinus problems Mouth/Throat: sore throat, bleeding gums, snoring, dry mouth, oral abnormalities, mouth ulcer, teeth abnormalities, mouth breathing

CARDIOVASCULAR Cardiovascular: chest pain on exertion, arm pain on exertion, shortness of breath when walking, shortness of breath when lying down, palpitations, known heart murmur, light-headed on standing

RESPIRATORY Respiratory: wheezing, shortness of breath, coughing up blood, sleep apnea

GASTROINTESTINAL Gastrointestinal: abdominal pain, vomiting, change in appetite, black or tarry stools, frequent diarrhea, vomiting blood

GENITOURINARY Genitourinary: urinary loss of control, difficulty urinating, increased urinary frequency, hematuria (blood),incomplete emptying

MUSCULOSKELETAL Musculoskeletal: muscle aches, muscle weakness, arthralgias/joint pain, back pain

INTEGUMENTARY (Skin) Skin: abnormal mole, jaundice, eczema, rash, itching, dry skin, growths/lesions

NEUROLOGIC Neurologic: loss of consciousness, weakness, numbness, seizures, dizziness, frequent or severe headaches, migraines, restless legs

PSYCHIATRIC Psych: depression, mania, sleep disturbances, restless sleep, feeling unsafe in relationship, alcohol abuse

ENDOCRINE Endocrine: fatigue, increased thirst, hair loss, increased hair growth, cold intolerance

HEMATOLOGIC/LYMPHATIC Hematologic/Lymphatic: swollen glands, easy bruising, excessive bleeding

ALLERGIC/IMMUNOLOGIC Allergy/Immunologic: runny nose, sinus pressure, itching, hives, frequent sneezing

I have had no problems with any body part for the past 6 months.(Stop, no additional info needed.)

None

OAA Patient Request for Confidential Communications Orthopaedic Specialists

Patient: Patient No.: Address:

Soc. Sec.: Phone:

Date of Birth: Please consider this a request for confidential communication of my protected health information (PHI). I understand that you will do your best to reasonably accommodate it.

Check all that apply to this request: Please do not phone me at home. Use the following alternative phone number to contact me:

______________________. Please do not phone me at work. Use the following alternative number to contact me:

______________________. Please send my mail, including my bills, to this alternative address: ________________________________________________________

________________________________________________________ ________________________________________________________

Please do not leave messages on my answering machine/voice mail. Please do not mail appointment cards to me. Please do not contact me by email. Other requests (describe in detail) Please release medical and billing information to:

________________________________________________________ ________________________________________________________ ________________________________________________________

_______ (initial) I understand that the physician or provider to whom I am making this request will make reasonable efforts to accommodate this request. I further understand that in some emergency situations, my PHI may be released. I acknowledge that I have received the Notice of Privacy Practice for OAA-Orthopaedic Specialists. OAA-Orthopaedic Specialists is authorized to use and disclose health information for treatment, payment and healthcare operations purposes consistent with its Notice of Privacy Practices. Note: Please print all information except signature. Patient: Signature of Patient (or patient’s personal representative): ________________________________ Date representative: ________________________________ Name of personal representative: ________________________________ Relationship to patient (or other authority): ________________________________

FINANCIAL POLICY Patient ID#: ___________________

Thank you for choosing OAA Orthopaedic Specialists as your orthopaedic specialty healthcare provider. We are committed to providing you and your family with the best available medical care. In our ongoing process to make sure that all of your medical needs are met, our staff will be available to discuss our fees and this policy with you. The Services you have elected to participate in means that you accept a financial responsibility on your part.

We ask that all responsible parties read and sign our financial policy as well as complete the patient information forms prior to seeing the physician.

Payments for all services will be due at the time services are rendered. In order to serve you better, we accept cash, check, Visa and MasterCard. As a courtesy to you, we will verify your coverage and bill your insurance carrier on your behalf; however, you are ultimately responsible for the entire bill. The only exception to patient responsibility for payment is for an appointment for employer requested work performance screenings. As the responsible party, please understand:

1. Your insurance policy is a contract between you, your employer (if applicable), and the insurance company. We are not a party to that contract. Our relationship is with you, not your insurance company. We will not become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance and “usual and customary” charge. As your medical provider, we will only supply factual information to facilitate claim processing.

2. If your insurance requires a referral for you to see an OAA Orthopaedic Specialists provider, it is your responsibility to provide our office with the referral. If your insurance company denies payment due to no referral, you, the patient, agree to pay OAA Orthopaedic Specialists in full for any charges incurred during your visit.

3. Fees for services, which include unpaid balances, deductibles, co-payments and in some cases coinsurance, are due at the time of service. Returned checks and unpaid balances may be subject to collection placement and collection fees.

4. All charges are your responsibility whether your insurance company pays or does not pay. If your insurance carrier does not remit payment within sixty days, the balance may be due in full from you. If any payment is made directly to you for services billed by OAA Orthopaedic Specialists, you recognize an obligation to promptly remit payment to OAA Orthopaedic Specialists.

5. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, after such default and upon referral to a collection agency or attorney by OAA Orthopaedic Specialists, I will be responsible for all costs of collecting monies owed, including collection agency fees.

6. The above does not apply for those patients that are considered Workers’ Compensation. However, be advised that as a compensation patient you may be held responsible for charges in the event that your claim is denied or not paid or determined not to be work related.

7. Our practice utilizes the services of Assistant Surgeons/Physician Assistants for medical services including surgical procedures. As with the other professional services, we will bill your insurance for these services; however, should your insurance not cover the charges, you may be held ultimately responsible.

8. The completion of disability and/or FMLA forms are not billable/reimbursable by insurance carriers, therefore fees are your responsibility for payment. OAA Orthopaedic Specialists fees related to completion of these documents is $10.00 which is expected to be paid upon presentation of forms for completion. Please allow 10 to 14 business days for completion of these forms.

9. If you need to cancel your scheduled appointment, OAA asks that you contact our office at least 24 hours in advance. OAA reserves the right to apply a $50 fee for any appointment not cancelled within the requested 24 hour timeframe.

We understand that financial problems may affect timely payment, so we encourage you to communicate any such problems to us, so that we may assist you in keeping your account in good standing. Our financial counselor is available to assist you or answer any questions you may have.

INSURANCE RELEASE INFORMATION

I HEREBY AUTHORIZE THE OFFICE OF OAA ORTHOPAEDIC SPECIALISTS TO RELEASE TO MY INSURANCE COMPANY ANY NECESSARY INFORMATION NEEDED TO FILE AND EXPEDITE PAYMENT ON MY CLAIM. I FURTHER ASSIGN ANY BENEFITS PAYABLE ON MY BEHALF TO OAA ORTHOPAEDIC SPECIALISTS. I UNDERSTAND I AM FINANCIALLY RESPONSIBLE FOR ANY BALANCE NOT COVERED BY MY INSURANCE CARRIER.

I UNDERSTAND THE ABOVE INFORMATION AND WILL BE RESPONSIBLE FOR THE PATIENT

LISTED BELOW

Printed Name of Patient Date of Birth

Signature of Patient or Responsible Party Date

Relationship if Other than Patient

Your medical provider is participating in a government program that encourages the adoption of electronic health records. This technology will lead to reduced health care costs, but it will also improve the quality of your care and our ability to communicate with you, our patients.

As part of this program, the government requires us to record the following demographic information about you:

Preferred language Race Ethnicity Date of birth Gender

The U.S. Centers for Disease Control and Prevention (CDC) provides the options for the race and ethnicity fields that match the data collection standards defined by the U.S. Office of Management and Budget (OMB) and the U.S. Bureau of the Census (BC). We maintain secure records and assure you that this information will remain confidential.

You can help us by reviewing the list of options below and providing your race and ethnicity information during registration or check-in. If you do not wish to provide this information, you may simply decline.

Thank you for your assistance!

Dear Patients,

Please identify your Race from the following CDC-defined options:

African African American Alaska Native American Indian American Indian

or Alaska Native Arab Asian Asian Indian Bahamian Bangladeshi Barbadian Bhutanese Black

Black or African American

Burmese Cambodian Chinese Dominica Islander Dominican European Fillipino Haitian Hmong Indonesian Iwo Jiman Jamaican

Japanese Korean Laotian Madagascar Malaysian Maldivian Melanesian Micronesian Middle Eastern

or North African Native Hawaiian or

Other Pacific Islander Nepalese Okinawan

Other Pacific Islander

Other Race Pakistani Polynesian Singaporean Sri Lankan Taiwanese Thai Tobagoan Trinidadian Vietnamese West Indian White

Central American Cuban Dominican

Hispanic or Latino/Spanish Latin American/Latin,

Latino

Mexican Not Hispanic or Latino Puerto Rican

South American Spaniard

Please identify your Ethnicity from the following CDC-defined options:

OAA Orthopaedic Specialists

Patient Name: ______________________________________ Date of Birth: _________________

Please specify your preferred language: English Spanish Other ______________