paul s. schwartz - dr. schwartz - east bay area...
TRANSCRIPT
PAUL S . SCHWARTZSURGERY, DISEASES AND INJURIES OF THE FOOT AND ANKLE, SPORTS MEDICINE
1 1 2 L a C a s a V i a # 1 3 0 , W a l n u t C r e e k , C A 9 4 5 9 8 • P H O N E ( 9 2 5 ) 9 4 3 - 6 2 0 3 • F A X ( 9 2 5 ) 9 4 3 - 1 7 3 6
Diplomate, American Board of Foot Surgeons
Fellow, American College of Podiatric Surgery
Date _____________________________
PATIENT INFORMATION:
Name _______________ _______________________________________________________________ M F _____________________________ Last First Middle Sex Birthdate
Address __ _________________________________________________________________________________________________________________________ Street City State Zip
(_______)________________________________________ S M D W _____________________ Telephone Marital Status Drivers License Number
(_______)__________________________________ Cell Phone Number
_________________________________________Email Address
EMPLOYER Name ___________________________________________________________________________ (_______)_________________________ Telephone
EMPLOYER Address ___________________________________________________________________________ _________________________________ Street City State Zip Occupation
SPOUSE (OR PARENT) INFORMATION:
Name _______________ _______________________________________________________________ M F _____________________________ Last First Middle Sex Birthdate
EMPLOYER Name ___________________________________________________________________________ (_______)_________________________ Telephone
EMPLOYER Address ___________________________________________________________________________ _________________________________ Street City State Zip Occupation
EMERGENCY INFORMATlON:
Name ___________________________________________________________________________________________________ ________________________ Relationship
Address ________________________________________________________________________________________ (_______)_________________________ Street City State Zip Telephone
PRIMARY PHYSICIAN: _________________________________________________________________________________________________________
______________________________________________________________________________
____________________________________________________________ ____________________________________________________
(page 1 of 5)Insured or Guardian’s Signature Patient’s Signature
MM / DD / YYYY
I hereby authorize Dr. Paul Schwartz to furnish to the above insurance company(s) or to a designated attorney, all information which said insurance company(s) or attorney may request. I hereby assign to Dr. Paul Schwartz all money to which I am entitled for medical and/or surgical expense relative to the service rendered by him, but not to exceed my indebtedness to said physician and/or surgeon. It is understood that any money received from the above named insurance company, over and above my indebtedness will be refunded to me when my bill is paid in full. I understand I am �nancially responsible to said doctor for charges not covered by this assignment. I further agree, in the event of non-payment, to bear the cost of collection, and/or Court costs and legal fees should this be required.
CONFIDENTIAL PATIENT PROFILE
PAST SURGERIES: (Please note year and side where applicable)
ACL surgery
Angioplasty
Angio with stent
Appendectomy
Arthroscopy ankle
Arthroscopy elbow
Arthroscopy hip
Arthroscopy knee
Arthroscopy wrist
Arthroscopy shoulder
Coronary artery bypass graft
Cardiac valve replacement
Carpal tunnel release
Cataract extraction
Gallbladder surgery
Colectomy
Colostomy
Fracture repair
What bone?
Gastric bypass
Year
Side:Left, Rightor Bilateral Year
Side:Left, Rightor Bilateral
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
L R B
Hernia repair
Hip replacement
Knee replacement
LASIK
Meniscus surgery
Muscle biopsy
Pacemaker
Rotator cu� repair
Small bowel resection
Thyroidectomy
Tonsillectomy
C-section
Tubal ligation
Hysterectomy
Prostate surgery
Shoulder replacement
Back/neck surgery
Dorsal column stim pain pump
Foot surgery
Type
TYPE OF SURGERY
SOCIAL HISTORY:Recreational Drug UseList
1
2
YEAR
ALLERGY REACTION
TYPE OF SURGERY
3
4
YEAR
ALLERGY REACTION
Other surgeries not listed above
Do you have an allergy to: Latex - Yes No Contrast Dyes -
Married
Number of Children
For Women:Is there a chance youmay be Pregnant?
Sons Daughters
Divorced ALCOHOL
TOBACCO
Single Widowed
Partner Type
Amount per day
Last drink
Type
Amount per day
Years used
Year quit
Yes No Iodine / Shell�sh - Yes No
Yes NoYes No
Yes No
(page 2 of 5)
L R B
L R B
L R B
CONFIDENTIAL PATIENT PROFILE PAUL S . SCHWARTZSURGERY, DISEASES AND INJURIES OF THE FOOT AND ANKLE, SPORTS MEDICINE
Pharmacy Name
MEDICATION DOSAGE FREQUENCY MEDICATION DOSAGE FREQUENCY
Pharmacy Phone Number
Pharmacy Address
1
2
3
4
5
6
7
8
9
10
STREET OR PO BOX NUMBER
CURRENT MEDICATIONS:
PAST MEDICAL HISTORY: (Please check all that apply)
CITY
Please list all current medications IF UNSURE CALL OR MAIL AN ACCURATE LIST AS SOON AS POSSIBLE. Please include vitamins, over the counter medications and supplements.
ZIPSTATE
(page 3 of 5)
MRI X-Ray EKG Bone Scan EMG/Nerve conduction Ultrasound CT/CAT Scan
Problems with anesthesia Injured by a metallic object or foreign body Stress test
If yes to any above, please explain:
Have you ever had any of the following?
CONFIDENTIAL PATIENT PROFILE PAUL S . SCHWARTZSURGERY, DISEASES AND INJURIES OF THE FOOT AND ANKLE, SPORTS MEDICINE
Meds | Insulin | Diet
(Circle the following)
Type I | Type IIType:
How is it controlled?
PAST MEDICAL HISTORY: (Please check all that apply)
Acid re�ux Emphysema Rheumatoid arthritis
AIDS/HIV Fibromyalgia Osteoporosis
Alcoholism Gallbladder disease Other lung problems
Alzheimers GERD Parkinson's disease
Anemia Gout Peptic ulcer disease
Angina (Chest pain) Hiatal hernia Psoriasis
Atrial �brillation Heart murmur Peripheral vascular disease
Arthritis Hepatitis Polio
Asthma High blood pressure Renal disease
Enlarged prostate In�ammatory bowel disease Scoliosis
Bleeding disorders Irregular heartbeat Seizure disorder
Cancer Juvenile rheumatoid arthritis
Kidney disease
Year of last seizure
What Type Shortness of breath
Lupus
Sleep apnea
Spinal stenosis
Spondyloarthropathy
Thyroid disease
Tuberculosis
Valvular disease
High cholesterol
Other illnesses not mentioned
Liver disease
Lyme disease
Migraine headaches
Mitral valve prolapse
Motion sickness
MRSA (Staph Infection)
Multiple sclerosis
Heart attack
Obesity
Osteoarthritis
Cerebrovascular accident (Stroke)
Congestive heart failure
COPD
Coronery artery disease
Crohn's disease
Depression
Diabetes
Drug abuse
DVT/PE (Blood Clot)
Eating disorder
Year
Year
Type I Type II
How is it controlled
Meds Insulin Diet
L R B
L R B
L R B
L R B
L R B
(page 4 of 5)
MUSCULOSKELETAL
Muscles
Weakness Location Onset
Cramps at rest Location Onset
Cramps with exertion Location Onset
Limitation of activity Location Onset
Limitation of movement Location Onset
Ankle/Foot
Limitation of movement
Pain
Redness
Sti�ness
Swelling
Neck
Pain Onset
Sti�ness Onset
Back
Pain Location Onset
Joints
Pain Location Onset
Side:Left, Rightor Bilateral
FAMILY HISTORY: Please list if any family member and medical history.
Arthritis Heart Attack Cancer Diabetes DVT/PE OtherType (blood clot)
Family Member
Arthritis Heart Attack Cancer Diabetes DVT/PE OtherType (blood clot)
Family Member
CONFIDENTIAL PATIENT PROFILE PAUL S . SCHWARTZSURGERY, DISEASES AND INJURIES OF THE FOOT AND ANKLE, SPORTS MEDICINE
CONFIDENTIAL PATIENT PROFILE
GENERAL HISTORY (Review of Systems): Please check if any of these apply
CONSTITUTIONAL:
Chills Fatigue
Fever Malaise
Night sweats
Weakness
Weight gain
Weight loss
None of the above apply
INTEGUMENTARY:
Contact allergy
Excess scar former
Itchy skin
Rash
Skin infections
Skin lesion
None of the above apply
METABOLIC / ENDOCRINE:
Cold intolerant
Hair loss
Heat intolerant
None of the above apply
CARDIOVASCULAR:
Chest pain
Cyanosis (Blueish Skin due to lack of oxygen) Heart murmur
Irregular heartbeat /palpitation
Leg swelling
Syncope (Fainting)
None of the above apply
Other Other Other
Other
HEENT:
Blurred vision
Double vision
Dysphagia (Di�culty swallowing) Ear drainage
Facial pain
Headache
Hearing loss
Hoarseness
Nasal congestion
Ringing in ears
Vertigo
Vision loss
None of the above apply
GASTROINTESTINAL:
Abdominal pain
Constipation
Black tarry stools
Diarrhea
Heartburn
Jaundice
Loss of appetite
Nausea
Vomiting
None of the above apply
NEUROLOGICAL:
Di�culty walking
Dizziness
Poor coordination
Memory loss
Muscle weakness
Paresthesia (Tingling)
Seizures
Tremors
None of the above apply
PSYCHIATRIC:
Anxiety
Depression
Insomnia
Other
HEMATOLOGIC:
Bleeding
Bruising
None of the above apply
Other
OtherOther
(page 5 of 5)
GENITOURINARY:
Dysuria (Painful urination)
Frequent urination
Hematuria (Blood in urine)
Urge incontinence
Urinary incontinence
None of the above apply
Other
IMMUNOLOGICAL:
Asthma Bee sting allergies
Contact dermatitis
Environmental allergies
Food allergies
Seasonal allergies
None of the above apply
Other
RESPIRATORY:
Chest pain (respiratory)
Cough
Dyspnea (Di�culty breathing)
Recent infections
Known TB exposure
Wheezing
None of the above apply
Other
Patient SignatureBy my signature I verify all the above information is correct to the best of my knowledge.
DateMM / DD / YYYY
PAUL S . SCHWARTZSURGERY, DISEASES AND INJURIES OF THE FOOT AND ANKLE, SPORTS MEDICINE