Lonestar-ortho.net

NEW PATIENT REGISTRATION
Contact Information
Patient Name (Last, First, MI): Primary Care Physician: How did you learn about our practice? O Referred by a Physician: O Internet / Website O Newspaper / Magazine O Referred by a Patient: Demographic Information
Social Security #: - - Gender: O Male O Female O Other O Co-Habitating O Married O Widow / Widower Preferred Language: Employer or School: Is todays visit: Work Related O Yes O No
3rd Party Liability O Yes O No
Auto Accident O Yes O No
Emergency Contact Information
Contact Name (Last, First, MI): Preferred Pharmacy
Primary Insurance Information
Primary Insurance: Relationship to Patient: O Self O Spouse O Child O Other Insured's Date of Birth: Insured's Social Security #: - - Employer/Group Name: Secondary Insurance Information
Secondary Insurance: Insured's Date of Birth: Workers' Compensation Information
Insurance Company: Date of Injury: Adjuster's Name: ASSIGNMENT OF BENEFITS
I authorize assignment of my insurance benefits to be paid directly to my physician for eligible medical and/or surgical services performed during
the course of my treatment. I authorize the release of medical information needed to determine benefits including medical, surgical, psychiatric, and/or substance abuse information. I understand that this order does not relieve me of my obligation to pay such bills if not paid by my insurance company, or any balance due after payments by my insurance company. Patient Signature: LSO – Patient Information - Page 1 of 1 ORTHOPAEDIC CENTER FOR OSTEOPOROSIS
Demographic Information
_ New Patient _ Established Patient
Osteoporosis Risk Factors
Have you had any Fractures within the last 3 months?
If Yes, where was your fracture? For patients over 50 years of age: Have you had any fractures since your 50th Birthday?
If Yes, Please list the location of the fracture (affected bone), and approximate date it occurred: Have you had any loss of height (gotten shorter) since age 20? If Yes, How much height loss? (estimate): Are you Post-Menopausal? (Applies to Female Patients Only) If Yes, At what age? O Check if due to Hysterectomy How many Falls have you had in the last 12 months? O More than 5 (How many?) How active have you been in the last 12 months? O Unable to walk O Not Very Active (Walking less than 1 mile per day) O Somewhat Active (Walking 1-2 miles per day) O Very Active (Walking 2 or more miles daily) How many Caffeinated beverages (Coffee, Tea, Cola, Energy drinks, etc) do you have each day (1 serving = 8oz) O Less than 1 per Day O 1 to 3 servings per day O More than 3 servings per day Did either of your parents have a Hip Fracture or Vertebral Fracture after the age of 50? Previous Treatment
Have you had a Bone Density Scan (DEXA) in the past 2 years?
Initials: Date & Time: Orthopaedic Center for Osteoporosis - New Patient Forms - Page 1 of 6 Medications
Are you currently, or have you ever taken any of the following medications? (If so, please indicate how long you took the medication,
and when was most recent time you took it?)
Medication
Duration (How long have you been taking?)
Last Dose
Fosamax (Alendronate) Didronel (Etidronate) Boniva (Ibandranate) Aredia (Pamidronate) Actonel ( Risedronate) Reclast (Zoledronate) Fortical ( Calcitonin) Miacalcin (Nasal Spray) Estrogen / Hormone Therapy Evista (Raloxifene) Forteo (Teriparatide) Prolia (Denosumab) Anticonvulsants (Gabapentin, Lyrica, Lamictal, etc.) Anticoagulants (Heparin, Coumadin) Opioids (Oxycodone, Hydrocodone, Oxycontin, etc.) Oral Steroids (Prednisone) PPIs (Nexium, Prilosec, etc) SSRIs (Lexapro, Celexa, Sertraline) (Additional Current Medications – Please list on Past Medical History Form) Initials: Date & Time: Orthopaedic Center for Osteoporosis - New Patient Forms - Page 2 of 6 PAST MEDICAL HISTORY
For each category, please indicate any conditions which you currently have or have had in the past:
No Medical Problems
O I do not have any current or previous medical conditions
Cardiovascular
O Hypertension
O TIA (Transient Ischemic Attack) O Atrial Fibrillation O Congestive Heart Failure Pulmonary
O Asthma
O Frequent Pneumonia O Supplemental Oxygen Requirement Gastrointestinal
O Gastric Reflux (GERD)
O IBS / Crohn's Disease / Ulcerative Colitis Renal
O Kidney Stones
O Kidney Infection O Renal Insufficiency O Dialysis-Dependent Genitourinary
O Enlarged Prostate (BPH)
O Sexual Difficulty O Urinary Incontinence O Menstrual Problems O Frequent or Chronic Urinary Tract Infection (UTI) Musculoskeletal
O Degenerative Arthritis
O Rheumatoid Arthritis O Osteoporosis / Osteopenia O History of Hip Fracture O Vertebral Fracture Endocrine
O Diabetes
O Thyroid Disease O Addison's Disease O Polycystic Ovarian Syndrome (PCOS) Neurologic / Psychologic
O Anxiety
O Bipolar Disorder O Peripheral Neuropathy O Carpal Tunnel Syndrome O Alzheimer's Disease O Parkinson's Disease O Multiple Sclerosis O Spinal Cord Injury O Traumatic Brain Injury (TBI) Hematologic
O Anemia
O Clotting Disorder O Taking Anti-Coagulant Medications ("Blood Thinners") O Deep Venous Thrombosis (DVT) O Pulmonary Embolism (PE) O History of Blood Transfusion O Sickle-Cell Anemia Immunologic
O Immune Disorder
O Long-term Steroid Therapy (e.g. Prednisone) O Immuno-Suppressant Medication O Organ Transplant O Sjogen's Syndrome Cancer
If you have been diagnosed with cancer, or have had cancer in the past, please select the appropriate bubble:
Please provide any additional details about type of cancer, when it was diagnosed (approximate year), any treatment (Including any Medications, Radiation, and/or Surgery), the name of your Oncologist, and the approximate date of your most recent Oncology follow-up appointment: Orthopaedic Center for Osteoporosis - New Patient Forms - Page 3 of 6 PAST MEDICAL HISTORY (CONTINUED)
Additional Medical Problems
If you have any additional medical problems not listed, or need to provide any additional information, please check the bubble marked
"yes", and provide details below:
O Yes, I have the following medical conditions: SURGICAL HISTORY
For each category, please indicate any surgeries which you have had:
Head & Neck
O Eye Surgery
O Facial Reconstructive / Plastic surgery Cardiothoracic
O Cardiac Bypass
O Angioplasty / Cardiac Catheterization O Pacemaker / Defibrillator O Cardiac Valve Surgery Abdominal
O Hernia Repair
O Gastric Bypass O Cholecystectomy (Gallbladder) O Esophageal Surgery O Stomach / Bowel Surgery O Organ Transplant O Kidney Surgery Pelvic
O C-Section
O Bladder Suspension O Prostate Surgery Vascular
O Varicose Vein Surgery
O Aortic Aneurysm Repair O Vascular Bypass O Carotid Endarterectomy O AV Fistula (Dialysis access) Neurologic
O Brain Surgery
O Ventricular Shunt O Cervical Spine Surgery O Lumbar Spine Surgery O Scoliosis Surgery O Carpal Tunnel Release O Ulnar Nerve Decompression Orthopaedic
O Fracture Repair
O Knee Replacement O Hip Replacement O Shoulder Arthroplasty O Arthroscopic Surgery Other Surgeries
O If you have had any surgeries not present above, please list them here:
Have you ever been hospitalized, for any reason?
O Never
O None besides those listed in Surgical History If you answered "Yes", please provide details including reason, approximate dates and length of hospital stay: Orthopaedic Center for Osteoporosis - New Patient Forms - Page 4 of 6 FAMILY HISTORY
Please indicate any medical conditions affecting your family members:
Mother
O Diabetes
O Mental Illness O Skeletal Dysplasia O Genetic Abnormalities O Unknown / Not Applicable Father
O Diabetes
O Mental Illness O Skeletal Dysplasia O Genetic Abnormalities O Unknown / Not Applicable Siblings
O Diabetes
O Mental Illness O Skeletal Dysplasia O Genetic Abnormalities O Unknown / Not Applicable Children
O Diabetes
O Mental Illness O Skeletal Dysplasia O Genetic Abnormalities O Unknown / Not Applicable If you answered "Other" to any of the above, please provide explanation below: SOCIAL HISTORY
Marital Status
O Single
O Separated / Divorced O Widow / Widower Education
O Grammar School
Employment
What is your current (or most recent) Occupation?
Please describe your Current Work Status:
O Working - Full Time O Working - Part Time O Seeking Employment O Physically unable to work / Disabled O Not working by choice (Retired - Homemaker - Student - etc.) Habits
Tobacco & Nicotine Products
O Current / Occasional User O Former user – Quit Date (Approximate): If you are currently using Tobacco or Nicotine products, please indicate the Type (select all that apply): O Chewing Tobacco O Nicotine Vaporizer / "e-Cigarette" O Nicotine Gum / Patch If you are currently using Tobacco or Nicotine products, please indicate how often: O At Least 1x per Week O At Least 1x per Month O Less than Once per Month O Less than 1 drink per Week O Weekly Do you have a History of Heavy Drinking or Alcoholism? Orthopaedic Center for Osteoporosis - New Patient Forms - Page 5 of 6 REVIEW OF SYSTEMS
For each category, please indicate all problems which you currently have:
Constitutional
O None
O Recent Unexplained weight Loss (More than 10 Pounds) O Recent Unexplained weight Gain (More than 10 Pounds) General
O None
O Muscle Weakness O Difficulty Standing O Difficulty Walking Head, Eyes, Ears, Nose, & Throat
O None
O Vision Problems O Difficulty Swallowing Cardiovascular
O None
O Shortness of Breath O Ankle / Feet Swelling Respiratory
O None
Gastrointestinal
O None
O Dark / Bloody Stools Musculoskeletal
O None
Integumentary
O None
O Skin infection Neurology
O None
O Frequent Headache O Balance Problems Psychiatric
O None
O Sleep disturbances O Feelings of hopelessness Genitourinary
O None
O Urinary incontinence O Pain with Urination O Frequent Urination O Incomplete voiding Orthopaedic Center for Osteoporosis - New Patient Forms - Page 6 of 6 AGREEMENT FOR OPIOID MEDICATION THERAPY
Introduction
The purpose of this agreement is to give you information about the medications you will be taking for pain management and to assure
that you and your physician comply with all state and federal regulations concerning the prescribing of controlled substances. A trial of
opioid therapy can be considered for moderate to severe pain with the intent of reducing pain and increasing function. The physician's
goal is for you to have the best quality of life possible given the reality of your clinical condition. The success of treatment depends on
mutual trust and honesty in the physician/patient relationship and full agreement and understanding of the risks and benefits of using
opioids to treat pain.
I (patient) understand the following (initial each):
_ Opioids have been prescribed to me on a trial basis. One of the goals of this treatment is to improve my ability to perform various functions, including return to work. These medications are being prescribed to make my pain tolerable but may not cause it to disappear entirely. If significant demonstrable improvement in my functional capabilities does not result from this trial of treatment, my prescriber may determine to end the trial. _ Drowsiness and slowed reflexes can be a side effect of opioids, especially during dosage adjustments. If I am experiencing drowsiness while taking opioids, I agree not to drive a vehicle or perform other tasks that could involve danger to myself or others. _ There is a risk that physical dependence or addiction to opioid medications can occur. Longer duration of therapy, higher doses of medications, and personal or family history of other drug or alcohol abuse increase this risk. If it appears that I may be developing addiction, my physician may determine to end the trial. I agree to the following (initial each):
_ I agree not to take more medication than prescribed and not to take doses more frequently than prescribed. _ I agree to keep the prescribed medication in a safe and secure place, and that lost, damaged, or stolen medication will not be _ I agree not to share, sell, or in any way provide my medication to any other person. _ I agree to obtain all prescription medication from one designated licensed pharmacy: Pharmacy:
_ I understand that my doctor may check a Controlled Substance Database or Prescription Monitoring Program at any time to check my compliance. _ I agree not to seek or obtain any mood-modifying medication, including pain relievers, muscle relaxers, or tranquilizers from any other prescriber without first discussing this with my prescriber. If a situation arises in which I have no alternative but to obtain my necessary prescription from another prescriber, I will advise that prescriber of this agreement. I will then immediately advise my prescriber that I obtained a prescription from another prescriber. _ I agree to submit to random urine, blood or saliva testing, at my prescriber's request, to verify compliance with my treatment plan, and to undergo be seen by an addiction specialist if requested. _ I authorize the doctor and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including this state's Board of Pharmacy, in the investigation of any possible misuse, sale, or other diversion of my pain medicine. I authorize my doctor to provide a copy of this Agreement to my pharmacy. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. I understand that any deviation from the above agreement, at any time, may be grounds immediate cessation of
all opioid therapy and may result in termination of the doctor/patient relationship with Dr. Bajaj, Dr. Evans, Dr.
Ratusznik, Dr. Thomas, or Dr. Werner.
Patient Signature:
I obtain my pain medication from my primary care doctor or pain management physician:
Dr.
, And I will continue to do so until I discuss any changes with Dr. Evans, Dr. Bajaj, Dr. Ratusznik, Dr. Thomas or Dr. Werner. Patient Signature:
Opioid Therapy Agreement - Page 1 of 1 PRACTICE POLICIES
Financial Obligations
I agree that in return for the services provided by Lone Star Orthopaedic and Spine Specialists I will pay my account at the time service
is rendered, or will make financial arrangements satisfactory to Lone Star Orthopaedic and Spine Specialists for payment. If my
insurance company or health plan designates co-payments and/or deductibles, I agree to pay them to Lone Star Orthopaedic and
Spine Specialists. All co-payments and past due balances are due and payable at the time of service. I understand and agree that if
my account is delinquent, a collection agency may be authorized to recover the unpaid amount.
Patient Initials:
HMO Referrals
If your insurance has designated a primary care physician (PCP), a prior authorization from your PCP is required to see a specialist. It
is your responsibility to work with your PCP and insurance carrier to obtain this authorization prior to your office visit with Lone Star
Orthopaedic and Spine Specialists. If authorization is not provided, either by you the Patient, or through your Insurance Carrier or PCP,
you will be asked to re-schedule your appointment until the authorization is available, or pay for the visit at the time of service and file
with your insurance carrier for reimbursement.
Patient Initials:
Self-Pay Accounts
Patients without an insurance plan at the time of service, and/or patients who are covered by insurance carrier with whom the practice
does not participate, are individually obligated to pay the full charges at the time of service
Patient Initials:
Non-Participating Insurance Accounts
Services provided to Patients who are insured by carriers with which the practice does not participate are considered "out-of-network." It
is the financial obligation of the patient with non-participating insurance carriers to pay the co-pay and/or visit in full at the time of
service.
Patient Initials:
If You Require Surgery
If you require surgery, your surgeon and supporting staff will work with you to select a date that will accommodate both schedules. Our
staff will review any anticipated financial responsibilities you may have. Keep in mind that these are estimates only, and are subject to
change once the surgery has been billed and insurance has paid. You may be asked to make a pre-payment to cover the amount of
your deductible/percentage for surgical care. This payment will be due before surgery is performed.
Please feel free to talk to our staff about a payment plan if you have a special financial situation. Our office will work with you to ensure that you receive the highest quality of care. Lone Star Orthopaedic & Spine Specialists will require that all balances being placed on a payment schedule be paid in full within 6 months – as such, payment plans are structured on a 6-month time frame.
Patient Initials:
Returned Checks
All returned checks will be assessed a $25.00 fee.
Patient Initials:
Signature:
Patient or Authorized Party Signature Practice Policies - Page 1 of 1 PRACTICE CONSENT FORM
Consent to Treat
I consent to necessary medical treatment as recommended by my physician. I understand that insurance may not cover all
recommended medical services, such as preventative health exams, immunizations, screening test, detailed phone consultations,
copies of medical records, or preparation of reports, forms, and summaries.
Patient Initials:
Privacy Notification
As permitted by the Health Insurance Portability and Accountability Act (HIPAA), I understand that my protected health information
may be used and disclosed by the physician, office staff, and others outside of this office who are involved in my care and treatment
for the purpose of providing health care services.
I acknowledge that I have been provided an opportunity to review the Notice of Privacy Practices which explains how my medical information will be used and disclosed. I understand that I am entitled to a copy of this document. Patient Initials:
Release of Information
I authorize Gurpreet S. Bajaj, M.D., Von L. Evans, M.D., John A. Thomas, M.D., Christopher Werner, D.P.M., and Jeffrey J.
Ratusznik, M.D. to discuss information with the following:
_ Family Members _ Coaching/Training Staff at my school. School Name: _ I restrict release of information to only the following: Name: Relation: _ Name: Relation: _ Patient Initials:
Medical Record Authorization
I authorize Lone Star Orthopaedic and Spine Specialists to obtain outside medical records including but not limited to Primary Care
Physicians, Hospitals, Imaging Centers, and Pharmacies:
Patient Initials:
I have read and fully understand the above consent for treatment, financial responsibility, release of medical records information, and insurance authorization. These authorizations shall remain until written notice is given by me revoking said authorization. Patient Signature:
Practice Consent - Page 1 of 1

Source: http://www.lonestar-ortho.net/Portals/2726/web-content/files/NewPatientPacketOsteoClinic.pdf