Today's Date :

Patient Registration Form

For Office Use Only
Account :
Doctor :
 
Office Location : FAIR LAWN
MAHWAH   
HOBOKEN  
CLIFTON     

 

Check In :

Paperwork Completed :

 

Have you been treated by Dr. Levitsky, Dr. Holden, Dr. Snyder, Dr. Bernstein, Dr. Shamash, Dr. Filion, William Thomson, PA-C, or Bryan Sheldon, Kimberly VanPelt PA-C in a local hospital?
Yes No
Have you ever been seen in the Fair Lawn Office Mahwah Office Hoboken Office or the Clifton Office
When were you treated by the medical provider?
All fields in GREEN are required
Last Name :
First Name :
Martial Status :
Single      
Married     Separated
Divorced   Widowed 
Street Address :
City :
State:
Zip Code :
Home Phone :
Business Phone :
Cell Phone :
Social Security Number :
Date of Birth :
Age :
Sex :
Male   Female
Name of Employer/School/Or Name of Parents Employer :
Occupation :
 
Street Address :
City :
State :
Zip Code :
In Case Of Emergency, Contact :
Phone :
Relationship :
Street Address :
City :
State:
Zip Code :
Please Explain Cause of Injury :
Pharmacy Name :
Pharmacy Address :
Pharmacy Phone:
Pharmacy Fax :

IS THE INJURY RELATED TO: (IF APPLICABLE, PLEASE CHECK ONE)

Motor Vehicle Accident     Work    Sports

Name of the Motor Vehicle Or Worker Compensation Carrier :
Address of Carrier :
Telephone Number :
Claim Number :
Adjusters Name :
How did you hear about GARDEN STATE ORTHOPAEDIC ASSOCIATES, P.A.?
MD REFERAL    FRIEND    OTHER

Primary Care or Internist Name :
Phone Number :
Street Address :
City :
State :
Name of Person To Bill For Todays Visit :
Home Phone :
Street Address :
City :
State:
Zip Code :
Relation To Patient :
Date of Birth :
Social Security Number :
Name of the Employer :
Street Address Of Employer :
City :
State:
Zip Code :
Business Phone :
Primary Insurance Company To Bill :
Policy Holders Address :
Policy Holders Employers Name :
Relationship :
Policy Holders Employers Address :
Insurance ID Number :
Policy Holders Name :
Policy Holders DOB :
Sex :
Local/Group Number :
Policy Holders Social Security Number :
Policy Holders Work Number :
Name of Secondary Insurance To Bill :
Policy Holders Address :
Policy Holders Employers Name :
Policy Holders Employers Address :
Insurance ID Number :
Policy Holders Insured Name :
Policy Holders DOB :
Sex :
Local/Group Number :
Policy Holders Social Security Number :
Policy Holders Work Number :
Account #:
Height:
Weight:
 
Are you allergic to any of the following:
  Yes   Yes
Adhesive Tape Metal
Iodine Contrast Dye
Latex Auto Immune
Eggs NONE
Do you have any drug allergies? (please list/explain) None
Indicate if you now have, or recently had, any of the following:
Mark if you have been diagnosed with any of the following:
  Yes   Yes
Bone Cancer Duodenal Ulcer
Breast Cancer Hepatitis, unspec type
Colon Cancer Hepatitis, spec type
Lung Cancer AIDS/HIV
Prostate Cancer Kidney Disease
Other Cancer Arthritis, unspec type
  Arthritis, osteo
(Please specify)   Arthritis, rheumatoid
Elevated Cholesterol Osteoporosis
Heart Attack Gout
Heart Disease Anxiety
Hypertension Depression
Stroke Thyroid Disease
Cataracts Anorexia/Bulimia
Glaucoma Diabetes
Asthma Obesity
Tuberculosis NONE
 
Mark family members who have been diagnosed with any of the
following:
  None Mother Father Brother Sister
Heart Disease
High Blood Pressure
Stroke
Asthma
COPD
Arthritis
Osteoporosis
Alzheimer’s
Diabetes (Type I)
Diabetes (Type II)
Bleeding/Clotting
Problem          
Deep Vein Thrombosis
Anemia
Brain Cancer
Breast Cancer
Colon Cancer
Liver Cancer
Lung Cancer
Prostate Cancer
Cancer (other)
Are you currently pregnant? Yes No Not Sure
Do you currently use any of the following:
None
  CONSTITUTIONAL
Fatigue
Fever
Unintentional Weight Gain
Unintentional Weight Loss
Night Sweats
 
 
  MUSCULOSKELETAL
Cramping
Pain in Back
Pain in Neck
Painful Joints
Stiffness in Joints
Weakness
Decreased Range of Motion
  EYES
Blurred Vision
Red Eye
Sensitivity to Light
Dryness
Infection
Wears glasses or contacts
  SKIN
Skin/Breast Color
Skin/Breast Change
Hair or Moles
Varicose Veins
Psoriasis
Rash
  ENT/MOUTH
Hearing Loss or Ringing
Nosebleeds
Mouth Sores
Sore Throat
Chronic Sinusitis
Gum Bleeding
   
  NEUROLOGICAL
Change in Alertness
Drooping on 1 Side of Face
Headache
Loss of Consciousness
Pain, Facial Severe
Seizures
Tingling
  CV
Blacking Out or Fainting
Chest Pain
Irregular Heartbeats
Dizziness
Palpitations
Deep Vein Thrombosis
  PSYCHOLOGICAL
Feel Nervous (Anxiety)
Feel Sad (Depression)
Trouble Sleeping
Recent Mood Swings
   
   
  RESPIRATORY
Chronic Frequent Cough
Bronchitis
Shortness of Breath
Wheezing
Spitting up blood
  ENDOCRINE
Appetite is Increased
Appetite is Decreased
Fatigue (Excessive)
Neck Has Enlarged
Thirst has Increased
  GI
Abdominal Pain
Nausea
Vomiting
Constipation
Diarrhea
  HEM/LYMPH
Infections Recurring
Reaction to Insect Bite
Anemia
Phlebitis
Post Transfusion
  GU
Urinary Tract Infections
Kidney Stones
Blood in Urine
Sexual Dysfunction
Enlarged Prostate
  ALLERGY/IMMUNE
Seasonal Allergies
Hives
Drug Reaction
Frequent Illness
   
Tobacco Products: None Cigarettes Smokeless Tobacco Cigars
Amount of cigarettes you smoke in an average day: 1 pack 1 ½ packs 2 packs 3 packs
Alcoholic Beverages: (less than 12 drinks/year) (1-13 drinks/month) (4-14 drinks/week) (gsreater than 2 drinks/day)
A drink is 1 shot of liquor, 1 glass of wine, or 1 bottle/can of beer
 Recreational drugs  Intravenous drugs
 NONE
Today’s Problem:

Reason for visit (indicate body part): Severity: Date of Injury:



Timing (how long have you had this problem):

Aggravating Factors:

Relieving Factors:


Are you taking any medications?             Yes            No
If yes, please list:

Medication Name  Dosage Strength



Have you ever had surgery?             Yes            No
If yes, please list:

Surgery  Date



Have you had any problem with anesthesia?             Yes            No
If yes, please list:


Which is your dominant hand?      Right             Left
Do you have any implants?      Yes     (Please specify)  
     No
Have you worked around metal?       Yes    (Please specify)   
     No
I hereby agree to be treated by Garden State Orthopaedic Associates, P.A. (Dr. Kenneth A. Levitsky, Dr. Douglas S. Holden, Dr. Samuel J. Snyder, Dr. Adam D. Bernstein, Dr. Steven Shamash, Dr. Dean T. Filion, William Thomson, PA-C, or Bryan D. Sheldon, Kimberly VanPelt 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 innetwork 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.
Patient/Guardian Signature :
Date Signed :
Insured’s Signature :
Date Signed :