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	Home > Forms > New Problem History		Thu 20 th Nov, 2008

Today's Date: Thu 20 th Nov, 2008

I have an appt. scheduled with Dr. Getzin on:

New Problem History Information Sheet
Name: (as it appears on your insurance card)	First: Middle: Last:
Preferred first name or nickname:
Your Email Address:	Your email address is required to send you a confirmation of your submission.
Date of Birth:
Were you referred by an Athletic Trainer at your school?	Name of ATC What school do you attend?
The reason for your visit? (e.g. L shoulder pain)
How long have you had this problem and what may have caused it?
Have you seen any other medical professional for this problem? If so, who?	Yes No
Have you had any radiological studies for this problem?( Eg X ray, MRI)? If so, please indicate the date and location	Yes No
Have there been any changes in your health since your last visit to our office? Please note any changes, including medications, surgeries.
Has your insurance coverage changed since your last visit? If so, please complete the information below:	Yes No

Primary Insurance
Insurance Name:
Co-Pay:
Type:
Patient Insurance ID:
Insurance ID:
Group #:
Other
Policy holder's Name:
Address:
City:
State & Zip:	,
Phone:
DOB:
M / F:	Male Female
Relationship:

Secondary Insurance (if applicable)
Insurance Name:
Co-Pay:
Type:
Patient Insurance ID:
Insurance ID:
Group #:
Other
Policy holder's Name:
Address:
City:
State & Zip:	,
Phone:
DOB:
M / F:	Male Female
Relationship:

Complete
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If you decide to print and fill out the forms you may bring them with you to your appointment, mail them to us at Cayuga Sports Medicine 310 Taughannock Blvd, Suite 5A, Ithaca, NY 14850, or fax them to us at 607-257-5973.

Last modified on : October 20, 2008

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