Herbert Mendelson, MD David Mendelson, MD Jeffrey Mendelson, MD Stephen Mendelson, MD Alice Mendelson, MD Anna Babushkina, MD Ferras Zeni, MD Martin Kornblum, MD Andres Munk, MD Sukhbir (Sonny) Guram, MD Giuseppe Paese, DO Anthony Oddo, DO Ms. Wednesday Hall, DO Jeffrey Klein, DPM History of Present Illness Form Patient Name: Birth Date: Age: Gender: □Male □Female Who Referred you to us: □ Hospital program □ Physician Referral □ Insurance Referral □ Advertisement □ Internet/Website □ Friend/Family Name: Primary Care Physician: Phone # ( ) Phone # ( ) Phone # ( ) Referring Physician: Pharmacy Name: Pharmacy Location: Height: Weight: What is the reason for your visit? Body Part ________ ______ □ Yes □ No □ Yes □ No □ Yes □ No Was there an injury? Job Related? Auto Accident? Date of onset/injury: Where did it happen? □Right □Left □Both Explain what happened: Are you currently on disability? □ Yes □ No No Pain Circle your pain level: 1 Unbearable 2 3 4 5 6 7 8 9 10 Reset Describe the location of your pain: Check the quality of your pain: □ Dull What makes the pain better?: What make the pain worse?: List any prior Ortho related treatments: □ Sharp □ Electrical □ Burning □ Pins & Needles □Physical Therapy □ Injections □Other (Explain): Have you had previous studies such as: MRI CAT Scan EMG Bone Scan X-rays Ultrasound Blood work Other(Explain) Date: Date: Date: Date: Date: Date: Date: Date: Facility: Facility: Facility: Facility: Facility: Facility: Facility: Facility: 14555 Levan Rd, Suite 215 / Livonia, MI 48154/ P 734.542.0200 / F 734.542.0220 11900 East 12 Mile Rd, Suite 110 / Warren, MI 48093/ P 586.261.1960 / F 586.261.1961 MendelsonOrtho.com Medical History Past Medical History: Have you ever had any of the following: Check all that apply, provide explanation in space below. □ □ □ □ □ □ □ □ □ □ □ □ AIDS/HIV Anxiety/Depression Arthritis Autoimmune Disorder Bleeding Disorder Blood Clots Blood Transfusions Cancer Diabetes Fibromyalgia Gout Heart Disease □ High Blood Pressure □ High Cholesterol □ Kidney Disease □ Liver Disease/Hepatitis □ Lung Disease □ Major Infection □ □ □ □ □ □ Neurological Disease Pacemaker RSD Stomach Ulcer Stroke Thyroid Disease Please explain: Family History Father Mother Living: Diseases: □ Yes □ No □ Unknown. □ No known significant family history □ Unknown □ Significant (add below) □Yes □No Are you Jehovah’s Witness? Surgical History Month/Year Living: Diseases: □ Yes □ No □ Unknown. □ No known significant family history □ Unknown □ Significant (add below) Are you willing to accept blood/blood products? Orthopedic Month/Year □ Yes Have you ever had a reaction to anesthesia? □Yes □No General □No Social History Occupation/Employer: Marital Status: □ Single □ Do you smoke/use tobacco? Did you in the past? Do you drink alcohol? Did you in the past? Married □ □ □ □ □ □ Yes □ Yes □ Yes □ Yes □ Widowed Number of children No How much? No How long? No Type/Weekly amount No Type/Weekly amount Allergies (Drug) Allergic to Are you allergic to Latex ? Divorced Date you quit: Reaction □ Yes □ No Can you take aspirin? 14555 Levan Rd, Suite 215 / Livonia, MI 48154/ P 734.542.0200 / F 734.542.0220 11900 East 12 Mile Rd, Suite 110 / Warren, MI 48093/ P 586.261.1960 / F 586.261.1961 □ Yes □ No MendelsonOrtho.com Medications Medication Dose Frequency Pain Medication Vit/Supp Dose Frequency Dose Frequency Review of Symptoms Indicate “yes” or “no” to any symptoms you have had in recent months. Indicate which symptoms you have had if multiple symptoms are listed. Symptom Yes No Skin rash, sore, or excessive bruising? Numbness or tingling? Fever, night sweats, or chills? Frequent nosebleeds? Cough, shortness of breath, wheezing, or asthma? Chest pain or pressure? Exposed to anyone with tuberculosis? Blacked out, lost consciousness or had a seizure? Abnormal swelling of legs or feet? Pain in the calves of your legs when you walk? Change in bowel or bladder habits? (ie. incontinence) Pain, stiffness, or swelling in your joints or back? Do you feel you are at risk for HIV or AIDS? Muscle weakness? Dizziness or falling? Travel outside the US? Who do you authorize us to speak to regarding your medical care? Please list below: Name Relationship E-Signature of Patient Patient Legal Representative (if applicable) Print name of Legal Representative 14555 Levan Rd, Suite 215 / Livonia, MI 48154/ P 734.542.0200 / F 734.542.0220 11900 East 12 Mile Rd, Suite 110 / Warren, MI 48093/ P 586.261.1960 / F 586.261.1961 Date: Date: Relationship: _____ _____ _____ MendelsonOrtho.com Billing Information Form ## !" ##$$% 1 #3 Responsible Party $&#' $ ())))))))))))))))))))))))))))))))) !*$+)))))))))))))))))))))))) $#+))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))) *$ , +)))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))) (+)))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))) $-' . +)))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))) , (+))))))))))))))))))))))))))))))))))))))))))))))))))))))))))) $#- $% #% 0$/#$% #/ $% # $#- $% #% 0$/#$% #/ $% 0 1 + 0 1 + 2"+ ! $ 2"+ ! $ PRINT FORM 27472 Schoenherr Rd, Suite 140 / Warren, MI 48088 / P 586.261.1960 / F 586.439.6232 MendelsonOrtho.com