Reach New Heights
We know your time is valuable, Dr. Nic & Dr. Masi appreciate your efforts in filling this out!
Patient Name
*
First Name
Last Name
What is your current gender identity? (Please check ALL that apply)
*
Male
Female
Transgender Male/Transman/FTM
Transgender Female/Transwoman/MTF
Gender Queer
Decline to answer
Other
Patient Birth Date
*
Please select a month
January
February
March
April
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June
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December
Month
Please select a day
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Day
Please select a year
2024
2023
2022
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Year
Phone Number
*
-
Area Code
Phone Number
Patient E-Mail Address
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
*
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
Date Signed
*
DateTime
What makes you want to be taller?
Ok to put as much or as little as you want here.
What's the story behind it?
Occupation ('student' if in school)?
Employer (which school if you are a student)?
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)
*
example 5.9
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?
*
YES
NO
What about kidney disease/problems?
*
YES
NO
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
Any Allergies?
*
Alcohol Consumption?
*
I don't drink
1-2 drinks/week
1-2 drinks/day
3+ drinks/day
other
Do you smoke?
*
No
0-1 pack/day
1-2 packs/day
2+ packs/day
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
N/A
Other
Anything else that we should know?
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!
Sincerely,
Should be Empty: