L. Nathan Gause, MD Ryan R. Snyder, MD Santosh George, MD … · 1 day ago · Leslie D. ˜omas, MD...
Transcript of L. Nathan Gause, MD Ryan R. Snyder, MD Santosh George, MD … · 1 day ago · Leslie D. ˜omas, MD...
![Page 1: L. Nathan Gause, MD Ryan R. Snyder, MD Santosh George, MD … · 1 day ago · Leslie D. ˜omas, MD Brett L. Wilson, PA-C. PATIE NT PAST SUR GICA L Angioplasty (heart cath) year Cataract](https://reader036.fdocuments.us/reader036/viewer/2022081613/5fb4c3e3a6604c53e819c037/html5/thumbnails/1.jpg)
TOSC-001 1
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130
www. libertyhospital.org
ATLIBERTY HOSPITAL
Orthopaedics
L. Nathan Gause, MD Santosh George, MDJoshua J. Niemann, MDR. Chris Reams, MD
Ryan R. Snyder, MDAndrew J. Taiber, MD Leslie D. �omas, MDBrett L. Wilson, PA-C
Patient InformationPATIENT NAME: PREFERRED NAME:
GENDER: MALE FEMALE DOB: / / AGE: SINGLE MARRIED WIDOW
RACE: (CIRCLE ONE) AMERICAN INDIAN ASIAN BLACK NATIVE HAWAIIAN WHITE UNKNOWN
ETHNICITY: (CIRCLE ONE) HISPANIC NON-HISPANIC UNKNOWN/NOT LISTED LANGUAGE:
ADDRESS: CITY: STATE: ZIP:
SSN# / /
HOME PHONE: CELL: EMAIL:
PATIENT’S EMPLOYER: OCCUPATION:
EMPLOYER ADDRESS: PHONE:
SPOUSE NAME: EMPLOYER: OCCUPATION:
EMPLOYER ADDRESS: PHONE:
EMERGENCY CONTACT (RELATIONSHIP): PHONE:
REASON FOR CONSULT: LEFT/RIGHT/BOTH (LIST BODY PARTS)
REFERRED BY: (FIRST AND LAST NAME OF PHYSICIAN OR HOSPITAL)
FAMILY PHYSICIAN: SEND RECORDS TO THIS PROVIDER? YES NO
PHARMACY INFORMATION IN CASE A PHYSICIAN CAN PRESCRIBE THROUGH THIS AVENUE
PHARMACY NAME: ___________________________________
PHONE: ___________________________________________
LOCATION : ________________________________________
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Comprehensive Health History
Have you ever, or do you:
SMOKE yes no Packs per day Age quit Any smokers in the home? yes no
SMOKELESS TOBACCO yes no quit How much? Year quit
DRINK ALCOHOL yes no What forms? Quantity Frequency
ILLICIT DRUGS yes no What forms? Quantity Frequency
ALLERGIES (medication & food) No known medication allergies No known food allergies
List all medication and food allergies, please identify reaction
Are you allergic to latex or latex based products?
See attached list
yes no
CAFFEINE USAGE yes no Co�ee Tea Soda Daily Amount
Tape? yes no Iodine? yes no
MEDICATIONS
Medication Dose How often do you take Medication Dose How often do you take
FAMILY HISTORY
Are your parents living? Mother yes no Father yes no Cause of death?
Please list any health conditions/serious illnesses that your mother, father, sister(s) or brother(s) have or have been told they have
had in the past (i.e. diabetes, heart condition, high blood pressure, stroke, high cholesterol, cancer, thyroid, etc.)
Father
Mother
Sister(s)
Brother(s)
PATIENT FULL LEGAL NAME DATE OF BIRTH
TOSC-001 2
TOSC-001 2
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130
www. libertyhospital.org
ATLIBERTY HOSPITAL
Orthopaedics
L. Nathan Gause, MD Santosh George, MDJoshua J. Niemann, MDR. Chris Reams, MD
Ryan R. Snyder, MDAndrew J. Taiber, MD Leslie D. �omas, MDBrett L. Wilson, PA-C
![Page 3: L. Nathan Gause, MD Ryan R. Snyder, MD Santosh George, MD … · 1 day ago · Leslie D. ˜omas, MD Brett L. Wilson, PA-C. PATIE NT PAST SUR GICA L Angioplasty (heart cath) year Cataract](https://reader036.fdocuments.us/reader036/viewer/2022081613/5fb4c3e3a6604c53e819c037/html5/thumbnails/3.jpg)
PATIENT PAST SURGICAL
Angioplasty (heart cath) year Cataract extraction year Lasik year
Angio (heart cath) w/stent year Gallbladder surgery year Liver biopsy year
Appendectomy year Colectomy (colon resection) year ORIF (fracture repair) year
Arthroscopy knee year Colostomy year Pacemaker year
Back surgery year Gastric bypass year Small bowel resection year
CABG (heart bypass) year Hernia repair year Thyroidectomy year
Carpal tunnel release year Hip/Knee replacement year Tonsillectomy year
Other
PATIENT PAST SURGICAL Women only
Augmentation mammoplasty (implants) year D & C year Myomectomy (Fibroidectomy) year
Bilateral tubal ligation year Hysterectomy (abdominal) year Reduction mammoplasty year
Breast Biopsy year Hysterectomy (vaginal) year Oopherectomy (ovary removal) year
Cesarean Section year Mastectomy year TAH/BSO year
Other
TOSC-001 3
PATIENT PAST MEDICALAllergies CHF (Conjestive Heart Failure) Immune system disorder
Anemia COPD (Chronic Obstructive Pulmonary Disease) Irritable bowel disease
Angina (chest pain) Coronary artery disease Liver disease
Anxiety Crohn’s disease
Migraine headaches
Arthritis
Depression
Myocardial infarction (heart attack)
Asthma
Diabetes
Osteoarthritis
Atrial fibrillation
Gallbladder Disease
Osteoporosis
Benign Prostatic Hypertrophy
GERD or chronic heartburn
Peptic ulcer disease
Blood clots locationP.E./DVTWhen:
Hepatitis A B C
Renal (kidney) disease
Cancer location
Hyperlipidemia (high cholesterol)
Seizure disorder
Cerebrovascular accident (stroke)
Hypertension (high blood pressure)
Thyroid high low other
Other
Have you ever had General Anesthesia? Any complications? Yes No
Malignant Hyperthermia
MRSA
Fibromyalgia
Blood clotting disorder
FIRST, MIDDLE, LAST:
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130
www. libertyhospital.org
ATLIBERTY HOSPITAL
Orthopaedics
L. Nathan Gause, MD Santosh George, MDJoshua J. Niemann, MDR. Chris Reams, MD
Ryan R. Snyder, MDAndrew J. Taiber, MD Leslie D. �omas, MDBrett L. Wilson, PA-C
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HEMATOLOGIC
HemophiliaDeep Vein ThrombosisSickle Cell
Have you ever received a Blood Transfusion?
PATIENT SIGNATURE: DATE/TIME:
Yes No When?
IMMUNOLOGIC
HIV Infection/AIDSLupusImmunosuppressed (on chemo/transplant)Are you on predisone (Deltasone) Yes No
HERNIA
GroinBelly ButtonIncisional
FIRST, MIDDLE, LAST:
TOSC-001 4
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130
www. libertyhospital.org
ATLIBERTY HOSPITAL
Orthopaedics
L. Nathan Gause, MD Santosh George, MDJoshua J. Niemann, MDR. Chris Reams, MD
Ryan R. Snyder, MDAndrew J. Taiber, MD Leslie D. �omas, MDBrett L. Wilson, PA-C
![Page 5: L. Nathan Gause, MD Ryan R. Snyder, MD Santosh George, MD … · 1 day ago · Leslie D. ˜omas, MD Brett L. Wilson, PA-C. PATIE NT PAST SUR GICA L Angioplasty (heart cath) year Cataract](https://reader036.fdocuments.us/reader036/viewer/2022081613/5fb4c3e3a6604c53e819c037/html5/thumbnails/5.jpg)
LAST NAME FIRST NAME MIDDLE NAME PREVIOUS LAST NICKNAME
SOCIAL SECURITY BIRTHDATE SEX
BILLING ADDRESS STREET CITY STATE ZIP CODE
COUNTY RACE LANGUAGE ETHNICITY
MARITAL STATUS PRIMARY CARE PROVIDER
HOME PHONE NUMBER DAY PHONE NUMBER CELL PHONE NUMBER
ALTERNATE PHONE FOR EMERGENCY E-MAIL
PAYER NAME
ADDRESS CITY STATE ZIP CODE
PLAN NUMBER POLICY NUMBER
GROUP NAME GROUP NUMBER EFFECTIVE DATE
SIGNATURE DATE
Patient
Insurance
Financial Policy
1. Fees are due and payable at the time of your appointment. If we are contracted with your insur-ance, you will be billed any remainder after we hear from them. As a courtesy, we accept cash, checks, Visa, Discover, and Master Card.
2. If you have an HMO or PPO insurance with a designated primary care physician, please make
card or information, you will be required to pay the entire fee including any lab services.3. All co-pays must be paid at the time of your service4. Not all services are a covered benefit in all contracts. If you have a question regarding benefits,
insurance policy is a contract between you and your insurance company.5. All services must be paid in full within 30 days after your insurance has paid their portion. If your
visit is due to a Motor Vehicle Accident, payment in full is due at the time of the service. 6. The person who brings a child for care is ultimately responsible for their bill. The physician will
not get involved in court decisions or support disputes.7. Accounts become past due after 30 days. We reserve the right to send an account to collections
if not paid in full8. All returned checks must be paid with cash or money order within 5 working days or they will be
9. 10. All deductibles and co-payments for Obstetric (OB) services must be paid in full by the 7th month
with regular payments due each month by cash, check or credit card.
I hereby acknowledge that I have read, understand, and agree to the terms of this document relating
to insurance coverage and payment of my bill.
PATIENT/GUARDIAN’S SIGNATURE PRINT PATIENT’S NAME & BIRTH DATE DATE
Signature On File
I authorize use of this form on all my insurance submissions. I authorize release of information to all of my insurance companies. I authorize direct payment to The Liberty Clinic. I permit a copy of this authorization to be used in place of the original. I understand I am financially responsible for all
charges whether or not covered by insurance.
SIGNATURE DATE
Review of Systems* (check yes or no if you currently are experiencing any of the following):
*Please inform the physician, medical assistant or front desk staffof any other medical conditions or concerns.
SYMPTOM YES NO
JOINT PAINS
JOINT SWELLING
JOINT STIFFNESS
UNSTEADY GAIT
NUMBNESS
TINGLING
UNEXPECTED WEIGHT LOSS
FEVER
CHILLS
POOR HEALING WOUNDS
SCARRING / KELOIDS
EASY BLEEDING
Alerts* (check yes or no for the following):
ALERT YES NO
PACEMAKER
BLOOD THINNER
DEFIBRILLATOR
PREMEDICATION PRIOR TO PROCEDURES
RHEUMATOID ARTHRITIS
RSD (REFLEX SYMPATHETIC DYSTROPHY)
ALLERGY TO SHELLFISH OR IODINE
ALLERGY TO LATEX
ALLERGY TO ADHESIVE
PAIN MANAGEMENT TREATMENT
FIRST, MIDDLE, LAST:
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130
www. libertyhospital.org
ATLIBERTY HOSPITAL
Orthopaedics
L. Nathan Gause, MD Santosh George, MDJoshua J. Niemann, MDR. Chris Reams, MD
Ryan R. Snyder, MDAndrew J. Taiber, MD Leslie D. �omas, MDBrett L. Wilson, PA-C
TOSC-001 5
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TOSC-001 6
2521 Glenn Hendren Drive, Suite 204, Liberty, Mo 64068
P 816-781-6066 F 816-792-5130
www. libertyhospital.org
ATLIBERTY HOSPITAL
Orthopaedics
L. Nathan Gause, MD Santosh George, MDJoshua J. Niemann, MDR. Chris Reams, MD
Ryan R. Snyder, MDAndrew J. Taiber, MD Leslie D. �omas, MDBrett L. Wilson, PA-C
Patient Name
Adults I hereby give permission for the following individual(s) to pick up my prescription and / or other documents in my absence. To ensure proper handling of all controlled substances, I understand they will be required to show proper photo identification each time.
1.
2.
3.
4.
PHARMACY INFORMATION IN CASE A PHYSICIAN CAN PRESCRIBE THROUGH THIS AVENUE
PHARMACY NAME:
PHONE:
LOCATION:
No one other than myself (patient) has permission to pick up my prescriptions and /or other articles in my absence.
Date of Birth
SIGNATURE DATE