ELBOW - New Patient Intake Form

Transcription

1 Place label here Kristofer J. Jones, M.D. ELBOW - New Patient Intake Form Name Date Occupation _ Age DOB 1) Were you referred to this office? No Yes, Name 2) Who is your Internist or Primary Care Physician? Full Name Phone Fax 3) Chief Complaint/Current Illness: a) Which side bothers you?: Right Left b) What is your chief complaint? (What problem brings you in today?) c) How long have you had this problem? d) Was this a result of an injury? Yes No How: 4) If PAIN is one of your complaints, please complete the following questions. If not, advance to Question #6 a) Is your pain located in the: What is your dominant arm? Front Back Inside Outside Right Left b) Rate the average intensity of your pain/discomfort. (0=no pain, 10=severe pain) ) Activity-Related Symptoms: 1) Do you have rest pain? Yes No 2) Do you problems with overhead activity or throwing? Yes No 3) Does your pain radiate down your arm? Yes No 4) Does your joint feel tight or stiff? Yes No 5) Can you do your normal activities of daily living? Yes No 6) Does your problem stop you from playing sports? Yes No 7) Does your problem stop you from working? Yes No 8) Does your joint catch or lock up? Yes No 9) Does your elbow feel unstable? Yes No Page 1

2 Kristofer J. Jones, M.D. Place label here 6) Do you ever have any of these additional symptoms? If yes, describe Stiffness Numbness Instability Weakness Painful Other 7) Have you tried any of the below? Relief of Symptoms? Medication Type: Physical Therapy # of sessions: Helpful? Injections If yes, where were they? Other Describe: 8) Imaging & Diagnostic Studies 1) Have you had an MRI or Xray? Yes No Findings: 2) Other studies (EMG, CT Scan, Bone Scan): 9) Please list all medications you currently use: 10) Do you have any allergies? Yes No : Latex Penicillin Sulfa Cephalosporins Other meds: 11) Are you currently or have you ever had problems with the following: Heart Problem Lungs Sleep Apnea High Blood Pressure Cancer Diabetes Arthritis Hepatitis, TB AIDS Liver problems Polio Epilepsy or seizures Bowels or colon Describe all YES responses Elbow Intake Form Page 2

3 Kristofer J. Jones, M.D. Place label here Bladder problem Kidney problem Balance problem Numbness or tingling Blackout or fainting OTHER MEDICAL PROBLEMS: 12) Please list all past surgeries and hospitalization: Surgery/hospitalization Date 13) Please list all important medical problems that you are currently being treated for or have been treated for in the past: Date 14) Do you drink alcohol? If yes, glasses per week? 15) Do you smoke? If yes, how much per week? How long have you smoked? 16) Do you: Use recreational drugs Describe Exercise regularly How often 17) Sports/Hobbies: 18) Family History of any conditions below: Problems with general anesthesia Problems with bleeding easily Heart attack 19) How tall are you? How much do you weigh? Patient Signature Date Physician Signature Kristofer J. Jones, M.D. Date Do not write below this line Notes: Elbow Intake Form Page 3

4 MRN: Patient Name: CONSENT FORM (Patient Label) UCLA Health Systems Santa Monica UCLA Medical Center and Orthopedic Hospital Stewart and Lynda Resnick Neuropsychiatric Hospital You and your Health care provider have agreed to correspond using electronic mail (E mail). This form provides guidelines for the intended use of this type of communication, and documents for your consent. IN A MEDICAL EMERGENCY, DO NOT USE E MAIL. CALL 911 E Mail Use: Privacy and Confidentiality: Generally, e mail correspondence should be between the provider and an adult patient 18 years or older, or parent or legal guardian of a minor. Unless your provider tells you specifically that the e mail will be conducted via a secure server, consider e mail like a postcard that can be viewed by unintended persons. In addition, the content of the e mail may be monitored by the hospital to ensure appropriate use. Discuss with your provider who will process your e mail messages during business hours, vacations or illness. All e mails regarding your care will be included in your medical record. Creating a Message: Content of The Message: On the Subject line, include the general topic of the message, for example, Prescription or Appointment or Advice. In the body of the message, include your name and your identification number (Medical Record Number) or your date of birth. E mail should be used only for non sensitive and non urgent issues. Types of information appropriate for e mail include: Questions about prescriptions Routine follow up inquiries Appointment scheduling Reporting of self monitoring measurements, such as blood pressure and glucose determinations. According to the California law, your provider may not communicate any lab results unless your e mail correspondence is conducted through a secure server. Additionally, e mail must never be used for results of testing related to HIV, sexually transmitted disease, hepatitis, drug abuse or presence of malignancy, or for alcohol abuse or mental health issues. UCLA Form #12005 Rev. (09/13) Page 1 of 2

5 MRN: Patient Name: CONSENT FORM (Patient Label) Response Time: Discuss with your provider the expected time in which to receive a response. If the expected time is exceeded, call your provider at the phone number below. Ending E Mail Relationship: Either you or your provider may request via e mail or letter to discontinue using e mail as a means of communication. Disclaimer: UCLA Health System, Santa Monica UCLA Medical Center and Orthopedic Hospital and Stewart and Lynda Resnick Neuropsychiatric Hospital are not responsible for e mail messages that are lost due to technical failure during composition, transmission and/or storage. I have read and understand the information above, and have had any and all questions answered to my satisfaction. I agree to the guidelines for e mail communication. * Patient or Representative Signature Date Time If signed by someone other than the patient, please specify relationship to the patient: * Patient E mail address (please print): Provider Name: Kristofer J. Jones, M.D. Telephone Number (310) Provider E mail address (please print): layvazyan@mednet.ucla.edu UCLA Form #12005 Rev. (09/13) Page 2 of 2