General Patient Information
We know your time is valuable, we appreciate your efforts in filling this out!
What is your current gender identity? (Please check ALL that apply)
Decline to answer
Patient Birth Date
Patient E-Mail Address
Street Address Line 2
State / Province
Postal / Zip Code
Emergency Contact Phone Number
Last 4 Social Security #
(Important for insurance auth. etc.)
How did you hear about us?
Primary Care Doctor, Address, Phone, Fax
Referring Provider (if same as above, ignore)
What Pharmacy do you prefer?
(if patient is a minor, please enter parent/guardian information)
Can we see your insurance card? FRONT
And BACK please.
Subscriber Date of Birth
Secondary Insurance Information (if applicable)
"None" if there is no secondary insurance
I hereby authorize my insurance benefits to be paid directly to Silicon Valley Orthopaedics. I understand I am financially responsible for non-covered services and balances remaining after insurance payment. I authorize Silicon Valley Orthopaedics to release any information required to process this claim.
Patient or Guarantor Signature
What Brings You In?
Reason for visiting us here @ SVO:
What's the story behind it?
Occupation ('student' if in school)?
Employer (which school if you are a student)?
Is this visit as a result of a workplace injury?
If work related, what is the date of injury on your claim?
What treatments have you tried?
Anti-Inflammatory or Pain Medications
Have you had any diagnostic imaging of your injured body part? (X-Rays, MRI, CT Scan, etc.)
Yes (please bring any disks, reports, and/or hard copies of images)
No (no worries, we have X-Ray, MRI on site if needed)
Patient Medical History
(Sorry we have to ask... it's very helpful, and kind of important)
Patient Height (Feet.Inches)
Patient Weight (lbs)
Medical/Health History (ex. High Blood Pressure, Diabetes, Heart Failure)
"none" if no medical history
Do you have a history of blood clots?
What about kidney disease/problems?
Please list any Surgeries/Operations (with rough dates if you can recall)
"none" if no history of surgery
Please list ALL your Current Medications (a separate list is OK)
"none" if no medications taken
I don't drink
Do you smoke?
Please list any family medical history
Review of Systems- Check box if you have any symptom below:
Constitutional: Fever; Chills; Fatigue; Weakness all over
Eyes: Eye pain; Blurred vision; Eye Trauma; I wear glasses/contacts
ENT/Mouth: Sore throat; Sinus drainage; Decreased hearing; Dizziness
Cardiovascular: Chest pain; Palpitations; Irregular heart beats; High Blood Pressure
Respiratory: Shortness of Breath; Wheezing; Asthma; Bronchitis; Chronic cough
Genitourinary: Urinary Frequency; Pain with urination; Difficulty passing urine; Urinary Tract infections
Gastroenterology: Abdominal pain; Nausea; Stomach ulcers/reflux; Heartburn; Diarrhea; Constipation; Loss of appetite
Musculoskeletal: Joint Pain; Back Pain; Myalgias; Bone fractures, Osteoarthritis, Rheumatoid Arthritis, Fibromyalgia
Integumentary: Skin masses/sores/ulcers/rashes/lesions/cancers; Burns; Foreign Body Sensation
Allergy/Immun: Allergy symptoms; Dermatitis, Frequent itching, Skin reactions, Runny nose
Neurologic: Weakness; Headache; Fainting; Stoke/TIA; Numbness; Tingling; Seizures/epilepsy; Balance problems; Falls
Psych: Depression; Anxiety; Substance Abuse; Heavy alcohol use; Mood swings
Review of System: Do you commonly experience any of these symptoms?
Seasonal allergies/hay fever, dermatitis, frequent itching,
skin reactions, reactions to latex/rubber gloves, runny nose
Fever, fatigue, unexpected weight loss, weakness all over
Cardiovascular: Chest pain, heart palpitations, rapid heart beats, irregular
heart beats, high blood pressure
Integumentary: Changes in skin color, skin rashes, skin masses, skin
sores/ulcers, skin cancers
Endocrine: Frequent thirst, frequent hunger, hyperactivity, hypoactivity,
growth changes, hair changes
Ears/Nose/Throat: Decreased hearing, ringing in the ears, dizziness,
Hematology/Lymphatics: Bleeding tendency, easy bruising, lymph node
Gastroenterology: Abdominal pain, nausea, stomach ulcers/reflux, heartburn, indigestion, appetite change, change in bowel habits,
diarrhea, constipation, loss of appetite
Musculoskeletal: Bone fractures, joint sprains, joint swelling, low back pain,
joint stiffness, osteoarthritis, rheumatoid arthritis, fibromyalgia
Neurological: Headaches, speech difficulty, stroke/TIA, numbness, tingling,
seizures, epilepsy, balance problems, falls
Eyes: Double vision, blurry vision, eye trauma, use of glasses/contacts
Psychiatric: Mood swings, sleep problems, depression, anxiety,
substance abuse, heavy alcohol use/drinking
Respiratory: Shortness of breath, asthma, bronchitis, chronic lung problems,
Genitourinary: Difficulty passing urine, incontinence, frequent urination,
urinary tract infections, painful menstruation/PMS
For any "yes" symptoms above, please describe below
Can we please have a selfie of you? (We're visual folks)
Now that wasn't too painful was it? Thank you for taking the time!
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