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Thu 20 th Nov, 2008    














Today's Date: Thu 20 th Nov, 2008

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

Patient History & Information
Name:
(as it appears on your insurance card)		 First: Middle:
Last:
Preferred name or nickname:
Marital Status: Married Single
Age:
Parent(s) or Guardian(s) if < 18 years old
Date of Birth:
M/ F: Male Female
Address:
City:
State & Zip: ,
Place of Employment or School:
Home Phone:
Work Phone:
Cell Phone:
Preferred Phone: Work Phone
Home Phone
Cell Phone
Home E-mail address: An email address is required to send you a confirmation of your submission.
Work E-mail address:
Preferred E-mail address: Home Email
Work Email
Reason(s) for your visit to Cayuga Sports Medicine?
How long have you had this problem?
Do you know what might have caused this problem?
If you have pain, can you quantify the pain from 0-10 where 10 is the worst pain in the whole world and 1 is very mild?
Does anything make your problem better?
Does anything make your problem worse?
Does this problem limit you from doing anything you want or need to do?
Have you been to a physician for this problem?
If so, what was the result?		 Yes No
Have you had any previous x-rays or MRI's for this injury?
If so, when and where?		 Yes No
   
Exercise
If you exercise, please list what you do (please include type, frequency and intensity). Please also list any repetitive motion activity (musician, sewing, machine work, etc.)
Do you play sports on an organized team?  Please list.
If you run regularly, please answer the questions below
How many miles do you run per week?
What is your training pace?
How long have you run for?
What is your best 5K time? 
What is your best marathon time?
Do you do speed walk? Yes No
Has there been any recent change in running or training regiment?
If you compete in other endurance sports (swimming, biking, triathlons, etc.). Please provide details about your racing and training.
   
Care
Primary Care Physician:
Referring Physician or other medical professional:
Were you referred by an Athletic Trainer at your school? Name of ATC

What school do you attend?
Phone/Address of referring professional:
Referred by friend/relative:
Date of Referral:
   
Emergency Contact
Name (first and last):
Relationship:
Home Phone:
Work Phone:  Extension:
Cell Phone:
Preferred Phone: Home Work Cell
   
Primary Insurance
Insurance Name:
Co-Pay:
Type:
Patient Insurance ID:
Insurance ID:
Group #:
Other
Policy holder's Name:
Address:
City:
State & Zip: ,
Phone:
DOB: This form can be sent if you don't know this information, but we need to know this information when you arrive for your appointment.
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: This form can be sent if you don't know this information, but we need to know this information when you arrive for your appointment.
M / F: Male Female
Relationship:
   
Past Medical History
Please list all your health problems, such as asthma, diabetes, heart disease, high blood pressure, kidney stones, etc.:
Exercise:
Adopted:
Arthritis:
Blood Disorders:
Bone Disease:
Cancer:
Cardiovascular:
Diabetes:
Hypercholesterol:
Hypertension:
Menstrual:
Musculoskeletal:
Other:
   
Family History
Please list maternal or paternal relative for each:
Heart disease:
Hypertension:
Hypercholesterol:
Diabetes:
Stroke:
Osteoarthritis:
Rheumatoid arthritis:
Osteoporosis:
Other:
   
Surgical Operations
Please list all surgical operations you have had and include the year in brackets, e.g., appendix removal (1999), heart bypass (2003), etc.
   
Allergies
Please list any allergies that you had what the reaction was:
   
Medications
Please list all the medication that you are taking now, including any steroids: (Cortisone, Prednisone, etc.) or that you have taken during the past year:
   
Pharmacy
Please list the drug store/pharmacy that you use
Name:
Location:
Phone:
   
Social History
How many children to you have?
Occupation:
Do you smoke?
How much do you drink alcohol?
Were you ever abused? Yes No
Substance abuse:
   
Review of Systems
Please check the box of any problem you are currently having:
General Genitourinary
appetite burning
weight discharge
fevers flank pain
night sweats increased frequency of urination
sleep hesitancy
other: nocturia
Constitutional pain on urination
weakness other:
fatigue Musculoskel
light-headedness back pain
weight loss joint pain
other: orthopedic injuries
Eyes swelling of joint
loss of vision numbness
blurry vision weakness
double vision other:
decreased vision Neurologic
jaundice headache
scintillations numbness
other: stroke
ENM & T tingling
hearing loss weakness
tinnitis other:
vertigo Skin
nose bleeds irritations
decrease hearing sores
sore throat new spots
other: other:
Cardiovascular / Respiratory Psychiatric
shortness of breath anxiety
wheezing depression
dyspnea suicidal ideation
cough other:
excessive sputum production Hematologic / Lymphatic
nocturnal dyspnea easy bruising
palpitations unusual bleeding
swelling in arms other:
hypertension Endocrine
chest pain cold intolerance
fainting diabetes
other: thyroid problem
Gastrointestinal fatigue
chronic constipation heat intolerance
chronic diarrhea other:
heartburn Integument
stool abnormalties rash
nausea/vomiting jaundice
abdominal pain itching
peptic ulcer disease other:
other:  
Allergic / Immunologic  
any seasonal or other allergies  
other:  
   
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.
 
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Last modified on : October 20, 2008
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