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Welcome to New York Sports & Joints
LIEN Accident Registration ( Slip or trip and fall, anything not related to WC/MVA)
Patient Demographics
Name
*
First Name
Last Name
Todays Date:
*
-
Month
-
Day
Year
Date
Date of Birth:
*
-
Month
-
Day
Year
Date
Age:
*
Sex assigned at birth:
*
Please Select
Male
Female
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Apt/Unit Number
City
State / Province
Postal / Zip Code
Were you a:
Driver
Passenger
Pedestrian
On a Scooter
Taxi Driver
Other
Emergency Contact
Relation
Please Select
Parent
Child
Sibling
Significant Other
Spouse
Friend
Other
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Employment information
Occupation:
*
Employer
Company/Organization Name
Company Point Of Contact
Please enter a valid phone number.
Are you currently working?
*
Please Select
Yes
No
When was your last day?
-
Month
-
Day
Year
Date
Part-Time or Full-Time
*
Part-Time
Full Time
Date of Accident
*
-
Month
-
Day
Year
Date
Pharmacy Name
Pharmacy Phone Number
Please enter a valid phone number.
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Attorney Name
*
Attorney Number
Please enter a valid phone number.
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Medical Questionnaire
History and Symptoms
What body parts are you here for today?
*
Are you Right Handed or Left Handed?
*
Right Handed
Left Handed
Ambidextrous
How long have you had this problem?
*
Was this a result of a fall or accident?
*
Yes
No
If YES, please give date:
*
-
Month
-
Day
Year
Date
Can you work or perform normal activities?
*
Yes
No
If "no", please list the resitrictions:
Check the symptom(s) associated with your chief complaint:
*
Pain
Numbness
Tingling
Weakness
Muscle Spasm
Other
If other, please specify:
Please indicate where you feel the pain and/or symptoms:
*
Left Elbow
Right Elbow
Left Wrist
Right Wrist
Left Hand
Right Hand
Left Knee
Right Knee
Left Ankle
Right Ankle
Left Foot
Right Foot
Left Shoulder
Right Shoulder
Left Hip
Right Hip
Neck
Lowback
Midback
On a scale from 0 to 5 (5 being the worst) how severe is your pain at the onset?
Please Select
0
1
2
3
4
5
On a scale from 0 to 5 how severe is your pain today?
Please Select
0
1
2
3
4
5
Check how bad your pain is based on the pictures of the six faces below:
*
0 - Very Happy, no hurt
2 - Hurts just a little bit
4 - Hurts a little more
6 - Hurts even more
8 - Hurts a whole lot
10 - Hurts as much as you can imagine (don't have to be crying to feel this much pain)
What is the quality of the pain? (Check all that apply)
Sharp
Shooting
Stabbing
Dull
Aching
Intermittent
Constant
Other
If other, please specify:
What makes your problem worse? (Check all that apply)
Standing
Sitting
Walking
Lifting
Exercise
Twisting
Bending
Coughing
Sneezing
Lying Down
Squatting
Other
If other, please specify:
*
What treatments have you had for this problem? (Check all that apply)
*
Physical Therapy
Massage
Stimulation (TENS)
Acupuncture
Epidural Injections
Bracing
Trigger Point Injections
Other
If other, please specify:
*
Do you have: (Check all that apply)
*
MRI Reports/Films
X-Ray Films
EMG (Nerve Conduction Studies)
CT Scans
Bone Scan
Other
Disco Gram
If other, please specify:
*
What medications have you tried for this condition?
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Past Medical History
Please check any of the following conditions that apply to yourself or a family member:
Diabetes
*
Self
Family
Not applicable
High Cholesterol
*
Self
Family
Not applicable
Hypertension
*
Self
Family
Not applicable
Strokes
*
Self
Family
Not applicable
Glaucoma
*
Self
Family
Not applicable
Hepatitis
*
Self
Family
Not applicable
Gout
*
Self
Family
Not applicable
HIV
*
Self
Family
Not applicable
Arthritis
*
Self
Family
Not applicable
Heart Problems
*
Self
Family
Not applicable
Cancer
Self
Family
Not Applicable
Asthma
*
Self
Family
Not applicable
Thyroid Disorder
*
Self
Family
Not applicable
Seizures
*
Self
Family
Not applicable
GI Ulcers
*
Self
Family
Not applicable
GERD Heartburn
*
Self
Family
Not applicable
Other medical conditions:
Height (In):
*
Weight (Lbs):
*
Surgical History
Please list all surgeries you have had: Year of the surgery, and type of surgery. You can list multiple surgeries, separated by commas.
*
Allergies
Please check any of the following allergies that may apply to you:
*
Aspirin
Seafood
Penicillin
Seasonal
Sulfa Drugs
No Known Allergies
Other
If other, please specify:
*
Medications
Please list any other medications, vitamins, or herbal supplements you are currently taking (You can type more than one in this box followed by commas):
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Social History and Review of Systems
Please check any of the following that apply to you:
*
Alcohol Use
Tobacco Use
Drug Use
None of these activities apply to me
Other
Please check if any of the following apply to you:
*
Hypertension
High Cholesterol
Cardiac Disease
Respiratory Disease
Bowel Problems/Disease
Stomach Ulcers/Hernias
Liver Disease
Bleeding Disorders/Anemia
Anxiety, Depression, or other conditions
Dentures, Braces, Loose Teeth/Caps, Bridges
Neurological Disorders (i.e., strokes, seizures)
Cancer
Eye Disease
Arthritis or Gout
Diabetes
Thyroid Disease
Kidney/Bladder/Prostate Disease
Abnormal Vaginal Bleeding/GYN Disease
Anesthesia Problems
Hearing Problems
None of these conditions apply to me
Have you had a flu vaccine?
*
Yes
No
Have you had the Pneumococcal Vaccine?
*
Yes
No
Have you had a Blood Transfusion?
*
Yes
No
Date of Blood Transfusion:
*
-
Month
-
Day
Year
Date
Have you had a reaction to a Blood Transfusion?
*
Yes
No
Do you have a Healthcare Proxy?
*
Yes
No
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Private Insurance
Optional
Insurance Company name
Insured Name
Member ID#:
Relationship to Patient
Please Select
Self
Spouse
Child
Other
Insured Date of Birth
-
Month
-
Day
Year
Date
Your signature indicates that you have read, understand, and agree with the policies and documents below:
Patient's Signature
*
Please upload any relevant medical report and your Photo ID
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