ORTHOPAEDIC ASSOCIATES OF S . AUGUSTINE , P.A.

1 Welcome to our office. We are committed to providing you with the most comprehensive care assist us in doing so by providing the following information, as well as your driver s license andinsurance card(s).Last Name:First Name:Middle:Soc Sec Number:--Date of Birth://Primary #:City:State:Zip Code:Phone (Home): ( )(Cell): ()Employer (Parent s Employer if the patient is a minor/child):Employer Phone: ( )Position:Emergency Contact:Phone: ()Relationship:(Please provide a secondary address if you are not a full-time resident of this area)Secondary #:Phone: ( )City:State:Zip Code:Primary Insurance:Secondary Insurance:Policyholder Name:Policyholder Name:Policyholder Date of Birth://Policyholder Date of Birth://Primary Care Physician:Phone: ()Referred by (Physician):How did you hear about us?INDIVIDUALS AUTHORIZED TO RECEIVE MY MEDICAL INFORMATIONI hereby authorize the designated parties below to request and receive any Protected Health Information (PHI) regarding mytreatment, payment, or administrative information related to my treatment or payment.

2 I understand that the identity ofdesignated parties must be verified before the release of any information by providing proof of identification ( Photo ID). Ifyou would like your health information/PHI to be accessible to any immediate family members ( spouse, child,parent), it is necessary to include them on the list Authorized to have access to my health information/PHI:Name: _____Relationship: _____Name: _____Relationship: _____Name: _____Relationship: _____Print Patient NamePatient / Guardian SignatureDatePATIENT PRIVACYI have read and understand the Notice of Privacy Practices posted in the lobby. A printed copy of the Notice of PrivacyPractices is available upon / Guardian SignatureORTHOPAEDICASSOCIATES OFST. AUGUSTINE , ORTHOPAEDIC Place St. AUGUSTINE , FL 320863055 CR 210 W, Unit # 110 St. Johns, FL 32259Ph (904) 825-0540 Fax (904) Reorder # 5/23/16 9:47 AM Page 1 ProviderAppointment Date Chart # Patient Name (Print)DOBAge F MDominant hand R L Did you bring x-rays?

3 Y NWho requested that you visit this office? (Name) MD PA Attorney None (Self-Referral)What is the main reason for this visit? How long ago did it start? Days Weeks Months Years. Have you had a problem like this before? Y N What body part is involved? Please mark in table below. If more than one, see QuestionnaireOffice Use Only:Referred By: _____On a scale of 0-10 (10 is the worst) how severe is your pain (write) 0 1 2 3 4 5 6 7 8 9 10 What is the quality of the pain? Sharp Dull Stabbing Throbbing Aching Burning The pain is Constant Comes and goes (Intermittent). Does your pain wake you from sleep? Yes No Do you have? Swelling Bruise Numbness Tingling Weakness Loss of control of bowel or bladderSince my problem started, it is: Getting better Getting worse UnchangedWhat makes your symptoms worse?

4 Standing Walking Lifting Exercise Twisting Lying in bed Bending Squatting Kneeling Stairs Sitting Coughing SneezingWhich make your symptoms better? Rest Elevation Ice Heat OtherWhat medications have you taken for this current problem?Are you in pain management? Y N Pain management physician s nameHave you had any of these treatments? Injection Y N Brace Y N Physical Therapy Y N Cane/Crutches Y NWere you seen in the for this problem? Y N Which DateAre you here today as a result of the visit? Y N. Who saw you in the (name) MD PAWhat tests/scans have you had for this problem? X-Rays MRI CAT scan EMG/NCSW here were these tests done?Have you already had surgery for a problem in this same area either recently or in the past? Y N Please list # 1 SurgeonCitydateProcedure # 2 SurgeonCitydateWhen is the last date you worked your regular job?

5 Are you currently receiving or plan to apply for: Disability Y N Workers' Comp. Y N Unemployment Y NIs this problem the result of an injury: Y NIf no, was it a gradual onset or sudden onsetIf yes, you MUST complete below:Where did injury occurDate the injury occurredHow did the injury occurWork related: Y N Auto related: Y N Driver Passenger PedestrianType of vehicleWhat did you hit/hit youNeckand R arm radiates L armto Neither RShoulder L RElbow L RHand L RPelvis L RKnee L RFoot Land R legBackradiates L leg to Neither RArm L RWrist LFinger RT 2 3 4 5 L RHip L RAnkle LToe RB 2 3 4 5 LPROBLEMPA I 11/24/15 7:58 AM Page 1 NAME:MRN:Appointment Date REVIEW OF SYSTEMS:CHECK ANY CONDITION BELOW THAT YOU HAVEOR CHECK NONED escribeMSJoint PainJoint StiffnessGIHeartburn UlcersNausea VomitingBlood in stoolENDOF requent ThirstFrequent UrinationAlways Hot or ColdCONSTW eight LossFrequent FeverLoss of appetiteEYEB lurred VisionDouble VisionVision lossENTH earing LossHoarsenessTrouble swallowingC-VASCC hest PainPalpitationsRESPC hronic CoughShortness of BreathCOPD AsthmaGUPainful UrinationBlood in UrineKidney ProblemsSKINF requent RashesSkin UlcersPsoriasisNEUROH eadachesDizzinessSeizuresPSYCHDrug / Alcohol ProblemDepressionSleep DisorderHEMEEasy bleedingHIV / AIDSH emophilia Oral Meds Diet NoneAre you Diabetic?

6 Y N TREATMENT: Insulin HAVE YOU EVER HAD? : Check any conditions below: I do not have any of the conditions listed belowBack painStomach ulcersStrokeFracture which bone?Bleeding ulcers Cancer site _____OsteoporosisKidney failureRheumatoid arthritisGoutHepatitisLiver disease Heart attackHigh blood pressureHeart failureLupusBlood Clotsthat you had to take blood thinners to treat? Y N When?Allergy: Do you have ALLERGIES to any medications? Y N If yes, please list all and reactionNamereactionNamereactionNamereac tionWhat medications do you currently take? None please list all belowMedicationDose/ MedicationDoseMedicationDose/ MedicationDoseMedicationDose/ MedicationDosePAST SURGICAL HISTORY:What operations have you had? When? NoneHave you ever had a reaction to anesthesia? Y NPAST HOSPITALIZATIONS (Not for surgery) NoneFamily History: Is your father still living? Y N Is your mother still living?

7 Y NHas any direct relative had any of the following disorders? If so, which relative?Hemophilia High Blood Pressure Diabetes Rheumatoid ArthritisDoes any direct relative have the same condition you are being seen for today? Y N RelationshipDaily Frequently / Drug Use: None Social Daily Frequently/ Have you in the past? Y N Do you chew tobacco? Y N Social History: Alcohol use: None Social Do you currently smoke? Y N packs per day Occupation:Martial Status: M S D WPLEASE SIGN: The information on these two forms are accurate to the best of my Office Use OnlyCompleteDate / / Review # 1 byMD Date / / Review # 2 byMD Date / / POS Reorder # 1103067 11/24/15 7:58 AM Page 2 PATIENT FINANCIAL AGREEMENTC ompletion of FormsCharges will be incurred for completion of special forms and reports, such as life insurance, disability,and so forth.

8 Payment in full will be collected when the form is received. Please allow five businessdays for of BenefitsMy signature, or legal guardian s, confirms that I have received ORTHOPAEDIC ASSOCIATES (OASA)Financial Policies pamphlet. It also permits OASA to bill and accept payment from my insurance plan,Attorney, or other agency paying my claims for medical services and items received by me. Theremaining unpaid portion of my claims is my financial responsibility. I will pay co-payments at time ofservice per my insurance contract. Please refer to the OASA Financial Policies pamphlet for detailedinformation on all Financial Policies, as well as, payment plans and Care financial responsibilityThe undersigned understands and agrees that he or she will be financially responsible to pay for anybalance not covered by his or her insurance company.

9 This is to include Deductibles, Co-pays and undersigned, if uninsured, agrees to pay a DEPOSIT prior to the visit and be financiallyresponsible for any remaining balance resulting from any and all undersigned also agrees to be responsible for any costs incurred should the balance be placedwith a third party for for care and treatmentI hereby give consent for medical care and treatment, along with braces, splints, and other itemsrelated to my care, as provided by ORTHOPAEDIC NamePrint NameORTHOPAEDICASSOCIATES OFST. AUGUSTINE , ORTHOPAEDIC Place St. AUGUSTINE , FL 320863055 CR 210 W, Unit # 110 St. Johns, FL 32259Ph (904) 825-0540 Fax (904) Reorder # 04 10 2013 13:19 Page 1 ORTHOPAEDIC ASSOCIATES OF ST. AUGUSTINE , ORTHOPAEDIC Place St. AUGUSTINE , FL 320863055 CR 210 W, Unit # 110 St. Johns, FL 32259Ph (904) 825-0540 Fax (904) POS Reorder # 1213203 Name: Account #: Date: Preferred Language: English Spanish OtherRace: American Indian Asian Black / African American White Alaskan Native Pacifi c Islander declineEthnicity: Hispanic/Latino Not Hispanic/Latino declinePharmacy Preference:NameLocationPhoneHow would you like to be contacted?

10 Mail Phone E-mailRequest access to your records via our patient portal Email: *EMAIL ADDRESS REQUIRED for portal accessSmoking Status - for patients 13 years and up every day some days former smoker never smok