Order Number For Office Use Only Today's Date Office Location Fair Lawn Mahwah Hoboken Clifton Parsippany Paramus Check in: Account Doctor Paperwork Completed Patient Registration Form Have you been treated by Dr. Levitsky, Dr. Holden, Dr. Bernstein, Dr. Shamash, Dr. Van Grouw, Dr. Cassilly, Dr. Fakharzadeh, Dr. Zachweija, William Thomson, PA-C, Bryan Sheldon, PA-C, Long Bui-Le, PA-C or Jeffrey Lee, PA-C in a local hospital? * Yes No Have you ever been seen in the Fair Lawn Office Mahwah Office Hoboken Office Clifton Office Parsippany Paramus When were you treated by the medical provider? When were you treated by the medical provider? Patient Information Last Name * First Name * Marital Status * Single Married Separated Divorced Widowed Street Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Home Phone Business Phone Cell Phone Pharmacy Phone Email * Social Security Number Date of Birth * Age Sex * Male Female Name of Employer / School / or Name of Parent's Employer Occupation Employer Address Employer City Employer State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Employer Zip Code In Case of Emergency, Contact: * Emergency Contact Phone * Relationship * Street Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Please Explain Cause of Injury: * Pharmacy Name * Pharmacy Address * Pharmacy Phone * Pharmacy Fax (MUST BE COMPLETED FOR PRESCRIPTION ISSUE/RENEWALS) RACE * Asian Black Hispanic Patient Refuse White Languages * English French German Other Polish Ethnicity * Latino Not Latino Patient Refuse IS THE INJURY RELATED TO: (If Applicable, Please Check One) Motor Vehicle Accident Work Sports PCP/Referral How did you hear about GARDEN STATE ORTHOPAEDIC ASSOCIATES, P.A.? MD Referral Friend Other Primary Care or Internist Name Primary Care Phone Primary Care Street Address Primary Care City Primary Care State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Billing and Insurance Information Name of Person to Bill for Today's Visit * Billing Phone * Billing Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Relation to Patient * Date of Birth * Social Security Number Name of the Employer * Billing Business Phone Street Address of Employer * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Primary Insurance Company to Bill Policy Holder's Address Policy Holder's Employer's Name Relationship Policy Holder's Employer's Address Sex Insurance ID Number Policy Holder's Name Policy Holder's DOB Local/Group Number Policy Holder's Social Security Number Policy Holder's Work Number Name of Secondary Insurance to Bill Policy Holder's Address Policy Holder's Employer's Name Sex Policy Holder's Employer's Address Insurance ID Number Insured Name Policy Holder's DOB Local/Group Number Policy Holder's Social Security Number Policy Holder's Work Number Patient Health History Account # Height * Weight * Are you allergic to any of the following: * Adhesive Tape Iodine Latex Eggs Metal Contrast Dye Auto Immune NONE Do you have any drug allergies? * Yes No Mark if you have been diagnosed with any of the following: History Bone Cancer Bone Cancer History Breast Cancer Breast Cancer History Color Cancer Colon Cancer History Lung Cancer Lung Cancer History Prostate Cancer Prostate Cancer History Other Cancer Other Cancer History Elevated Cholesterol Elevated Cholesterol History Heart Attack Heart Attack History Heart Disease Heart Disease History Hypertension Hypertension History Stroke Stroke History Cataracts Cataracts History Glaucoma Glaucoma History Asthma Asthma History Tuberculosis Tuberculosis History Duodenal Ulcer Duodenal Ulcer History Hepatitis, Unspecified Type Hepatitis, unspec type Hepatitis, Specific Type Hepatitis, spec type History AIDS/HIV AIDS/HIV History Kidney Disease Kidney Disease History Arthritis, Unspecified Type Arthritis, unspec type History Arthritis, Osteo Arthritis, osteo History Arthritis, Rheumatoid Arthritis, rheumatoid History Osteoporosis Osteoporosis History Gout Gout History Anxiety Anxiety History Depression Depression History Thyroid Disease Thyroid Disease History Anorexia/Bulimia Anorexia/Bulimia History Diabetes Diabetes History Obesity Obesity History None None Mark family members who have been diagnosed with any of the following: Heart Disease * None Mother Father Brother Sister High Blood Pressure * None Mother Father Brother Sister Stroke * None Mother Father Brother Sister Asthma * None Mother Father Brother Sister COPD * None Mother Father Brother Sister Arthritis * None Mother Father Brother Sister Osteoporosis * None Mother Father Brother Sister Alzheimer's * None Mother Father Brother Sister Diabetes (Type I) * None Mother Father Brother Sister Diabetes (Type II) * None Mother Father Brother Sister Bleeding/Clotting Problem * None Mother Father Brother Sister Deep Vein Thrombosis * None Mother Father Brother Sister Anemia * None Mother Father Brother Sister Brain Cancer * None Mother Father Brother Sister Breast Cancer * None Mother Father Brother Sister Colon Cancer * None Mother Father Brother Sister Liver Cancer * None Mother Father Brother Sister Lung Cancer * None Mother Father Brother Sister Prostate Cancer * None Mother Father Brother Sister Cancer (other) * None Mother Father Brother Sister Have you experienced any of the following: Constitutional Fatigue Fever Unintentional Weight Gain Unintentional Weight Loss Night Sweats Eyes Blurred Vision Red Eye Sensitivity to Light Dryness Wears Glasses or Contacts ENT/Mouth Hearing Loss or Ringing Nosebleeds Mouth Sores Sore Throat Chronic Sinusitis Gum Bleeding CV Blacking Out or Fainting Chest Pain Irregular Heartbeats Dizziness Palpitations Deep Vein Thrombosis Respiratory Chronic Frequent Cough Bronchitis Shortness of Breath Wheezing Spitting up Blood GI Abdominal Pain Nausea Vomiting Constipation Diarrhea GU Urinary Tract Infection Kidney Stones Blood in Urine Sexual Dysfunction Enlarged Prostate Musculoskeletal Cramping Pain in Back Pain in Neck Painful Joints Stiffness in Joints Weakness Decreased Range of Motion Skin Skin/Breast Color Skin/Breast Change Hair or Moles Varicose Veins Psoriasis Rash Neurological Change in Alertness Drooping on 1 Side of Face Headache Loss of Consciousness Pain, Facial Severe Seizures Tingling Psychological Feel Nervous (Anxiety) Feel Sad (Depression) Trouble Sleeping Recent Mood Swings Endocrine Appetite is Increased Appetite is Decreased Fatigue (Excessive) Neck has Enlarged Thirst has Increased Hem/Lymph Infections Recurring Reaction to Insect Bite Anemia Phlebitis Post Transfusion Allergy/Immune Seasonal Allergies Hives Drug Reaction Frequent Illness Are you currently pregnant? * Yes No Not Sure Do you use any of the following: Tobacco Products? * None Cigarettes Smokeless Tobacco Cigars Smoking status: current everyday? current somedays? former? Amount of cigarettes you smoke in an average day? 1 pack 1 ½ packs 2 packs 3 packs If less than 1 pack, number of cigarettes per day: Have you ever smoked? * Yes No Are you exposed to second-hand smoke? * Yes No Alcoholic Beverages (a drink is 1 shot of liquor, 1 glass of wine, or 1 bottle/can of beer): * Less the 12 drinks / year 1-13 drinks / month 4-14 drinks / week more than 2 drinks / day Do you use: * Recreational drugs Intravenous drugs None Today's Problem Body Part * Severity Date of Injury Reason for visit * Timing (how long have you had this problem) * Aggravating Factors Relieving Factors Are you taking any medications? * Yes No Have you ever had surgery? * Yes No Have you had any problem with anesthesia? * Yes No What is your dominant hand? * Left Right Do you have any implants? * Yes No Have you worked around metal? * Yes No I hereby agree to be treated by Garden State Orthopaedic Associates, P.A. (Dr. Kenneth A. Levitsky, Dr. Douglas S. Holden, Dr. Adam D. Bernstein, Dr. Steven Shamash, Dr. Brian Van Grouw, Dr. Ryan Cassilly, Dr. Frederick Fakharzadeh, Dr. Erik Zachwieja, William Thomson, PA-C, or Bryan D. Sheldon, PA-C, Long, Bui-Le PA-C, Jeffrey Lee, PA-C) I acknowledge full responsibility for the payment of services rendered to me and agree to pay for such services in full, regardless of insurance or third party involvement, unless otherwise prohibited by law • I have been informed as to my in-network or out-of-network status prior to my visit • I authorize the practice to release to my insurance company or any of my third party payors any information needed to determine my insurance coverage • I authorize you to file claims with all insurance and third party carriers and further authorize and direct my insurance benefits to be paid directly to Garden State Orthopaedic Associates, P.A. 28-04 Broadway, Fair Lawn, NJ 07410 Tax ID #222814819 Please note that our office makes supplies available for your convenience. All medical supplies must be paid for at the time of your visit. Patients are responsible to pay a 1% per month finance charge on all unpaid balances which exceed 30 days. I verify the accuracy of the above information and authorize release of information as provided. Parent/Guardian Signature Date Signed Insured's Signature Date Signed
