Saturday Sports Clinic Pre-Registration Form

Patient Name Date of Visit Reason for Visit Side Right Left Both Who referred you Are you at the Saturday Sports Clinic If your injury the result of an accident, how did it happen Date of injury and where did it happen? Is it a Workers Comp Claim Yes No Was this a Motor Vehicle Accident? Yes No If not an injury, how long has it bothered you Have you taken ANY medications for this problem (Prescription or OTC): Have you had any treatment for this problem (Doctors, Physical Therapy, etc.,) Rate you pain/discomfort on a scale of 1-10 (1 = little pain, 10 = Severe Pain) Quality of the pain: Sharp Dull Throbbing Burning What makes your condition/injury better What makes you condition/injury worse: Please list any allergies to medications List all current medications. Include dosage and reason. Surgical History

General Patient Information

First Name Middle Name Last Name Social Security Number Date of Birth Sex Female Male Marital Status Married Divorced Widowed Single Widow/Widower Legally Separated Unknown Language Preference English Espanol Ethnicity Hispanic/Latin Not of Hispanic/Latino Race African-American/Black American Indian/Native Alaskan Asian/Oriental/Eastern Indian Native Hawaiian White/Hispanic Decline Unknown Street Address Street Address 2 City State * Zip Code Email Address Home Phone Cell Phone Best time to contact you? Morning Day Evening

Past Medical History

Have you ever had (check all that apply) Excessive Bleeding leg swelling Diabetes Rheumatoid Arthritis Osteoporosis Heart Swelling Osteoarthritis Calf Pain Ulcer Reaction to Anesthesia Heart Attack Irregular Heartbeat Hypertension On blood thinner/Aspirin Blood/Clot Sleep Apnea COPD Fibromyalgia Hepatitis Muscle Disease Kidney Disease Gout Stroke Asthma Thyroid Disease Other Conditions

Asthma Mother Father Brother Sister Daughter Son Cancer Mother Father Brother Sister Daughter Son Diabetes Mother Father Brother Sister Daughter Son High Cholesterol Mother Father Brother Sister Daughter Son Hypertension Mother Father Brother Sister Daughter Son Heart Disease Mother Father Brother Sister Daughter Son Lupus Mother Father Brother Sister Daughter Son Rheumatoid Arthritis Mother Father Brother Sister Daughter Son Seizures Mother Father Brother Sister Daughter Son Stroke Mother Father Brother Sister Daughter Son Thyroid Disease Mother Father Brother Sister Daughter Son

Social History

Occupation Employer Number of Children Tobacco Use Yes No Packs per day Years of smoking Alcohol Use Yes No Drinks per week Marijuana use Yes No Fitness Activities

Emergency Contact Information

Name Phone Number Relationship to the Patient

Guarantor/Responsible Party Information

(If different from above)

First Name Middle Name Last Name Relationship to Patient Social Security Number Date of Birth Street Address Street Address 2 CIty State Zip Code Email Address Cell Phone Employer Name (If not employed, enter None) Employer Address Employer City Employer State Employer Zip

Patient Insurance Information

Enter Not Applicable (N/A) if self pay

Please bring insurance card and photo ID

Primary Insurance Company Name Insurance Address Insurance City Insurance State Insurance Zip Name of Policy Holder Relationship to Patient Date of Birth Policy Holder Employer Employment Status Full Time Part Time Insurance ID Number Group Number Primary Insurance Phone Number

Patient Secondary Insurance Information

Secondary Insurance Company's Name Secondary Insurance Address Secondary Insurance City Secondary Insurance State Secondary Insurance Zip Name of Policy Holder Relationship to Patient Date of Birth Policy Holder Employer Employment Status Full Time Part Time Insurance ID Number Group Number

Tell Us About Your Primary Care Physician

Do you have a primary care physician? Yes No

If yes, please tell us about them:

Primary Care Physician First Name Primary Care Physician Last Name