today’s date: (to move through the form, use the tab key
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Atlantic Sports Health111 Madison Avenue, Suite 400, Morristown, NJ89 Sparta Avenue, Suite 205, Sparta, NJ
Page 1 of 7
Today’s Date:(To move through the form, use the tab key or left mouse button)
/ /
PATIENT INFORMATION
NewAre you a new or existing patient? Existing
Who referred you to our office?
Last Name: First: Middle:
Street Address: Apartment #:
City: State: ZIP Code:
Phone: Mobile: Email:
Sex: Male
Single
Female
Married Separated Divorced Widowed
Date of Birth: / / Age:
Marital Status: SS#:
Language: Race:
Emergency Contact Name: Phone: Relationship:
PATIENT EMPLOYMENT INFORMATION
GUARANTOR INFORMATION – Information on who’s financially responsible for the patient
––
Active MilitaryEmployment Status: Employed Full-Time Employed Part-Time Self-EmployedNot Employed Retired Student Other
Employer or School: Phone & Extension: Occupation:
Address:
City: State: ZIP Code:
SelfRelationship to Insured: Spouse Child Parent Employee Other
Last Name: First: Middle:
Street Address: Apartment #:
City: State: ZIP Code:
Sex: Male Female Date of Birth: / /
Single Married Separated Divorced WidowedMarital Status:
Last: First: DOB: / /
Atlantic Sports Health111 Madison Avenue, Suite 400, Morristown, NJ89 Sparta Avenue, Suite 205, Sparta, NJ
Page 2 of 7
GUARANTOR EMPLOYMENT INFORMATION
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Active MilitaryEmployment Status: Employed Full-Time Employed Part-Time Self-EmployedNot Employed Retired Student Other
Employer or School: Phone & Extension: Occupation:
INSURANCE INFORMATION
Address:
City: State: ZIP Code:
Name of Insurance Company:
Policy Holder Last Name: First: Middle:
SS#: –– Date of Birth: / /
Name: Phone: Did he/she refer you to us?
YOUR PRIMARY CARE PHYSICIAN
Yes No
Address:
City: State: ZIP Code:
Name: Phone: Fax:
YOUR PHARMACY
Insurance coverage varies greatly. Practice Associates & Atlantic Health System will file your claim with your insurance carrier and will bill you for any charges, including copayments and deductibles, not covered after being sent to your carrier. All radiological, laboratory, and dietician services are billed as a Hospital Outpatient Service. Please keep in mind that the billing of insurance is a courtesy to you. Your insurance policy is a contract between you and your insurance company. Communication with your insurance company is your responsibility.
I ACCEPT THE PAYMENT TERMS AS DETAILED ABOVE AND UNDERSTAND THAT ULTIMATELY I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES:
PAYMENT GUARANTEE
Address:
City: State: ZIP Code:
Patient/Guarantor Signature
Last: First: DOB: / /
Atlantic Sports Health111 Madison Avenue, Suite 400, Morristown, NJ89 Sparta Avenue, Suite 205, Sparta, NJ
Page 3 of 7
CURRENT MEDICAL CONDITION
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Please describe the reason for your visit. If describing an injury or pain, please be as specific as possible (eg, left elbow, back of right knee).
Date of injury or onset of problem: / /
Have you had X-rays or other radiological images taken for this problem? If yes, please indicate date and place.
Please rate your level of pain using the scale below.
Have you had treatment and/or physical therapy for this problem? If yes, indicate type and duration of treatment.
Have you taken any medications for this problem? If yes, please list medication and dosage.
Are you pregnant or suspect you may be pregnant? Yes No
Date of last menstrual period: / /
Are you breast feeding? Yes No
Height:
Weight:
feet inches
pounds
Last: First: DOB: / /
Atlantic Sports Health111 Madison Avenue, Suite 400, Morristown, NJ89 Sparta Avenue, Suite 205, Sparta, NJ
Page 4 of 7
ConstitutionalRecent weight changes
# pounds loss gainFever, sweats, chills
EyesEye disease or cataractsWear glasses/contact lensesBlurred or double visionGlaucoma
Ears/Nose/Mouth/ThroatHearing loss or ringingChronic sinus problemsNose bleedsSore throat or voice change
CardiovascularHeart murmurMitral valve prolapseRheumatic feverHigh blood pressure medicationLow blood pressureChest pain or angina pectoris in
last 30 daysPalpitationCongestive heart failureIrregular pulse/atrial fibrillationHistory of heart attackWhen?Feet, ankle or hand swellingCoronary artery diseaseCoronary angiogramWhen?Heart surgeryWhen?Peripheral vascular disease
RespiratoryChronic or frequent coughsEmphysema or COPDAsthmaBronchitisTuberculosis or positive TB skin testShortness of breath while walking or
lying flatWheezingPneumoniaSpitting up bloodSleep apnea
GastrointestinalAbdominal painEsophageal varicesNausea or vomiting
Gastrointestinal (cont’d)Frequent diarrheaChange in bowel movementPainful bowel movements or
constipationRectal bleeding or blood in stoolStomach ulcerVomiting bloodHistory of liver diseaseJaundice/gall bladder diseaseHepatitisAscitesHemorrhoids
GenitourinaryFrequent urinationBurning or painful urinationBlood in urineChange in force of stream when
urinatingIncontinence or dribblingKidney stonesMale – testicle pain
Date of last PSA:
Date of LMP:Hysterectomy or tubal ligationKidney diseaseKidney failureHemo dialysis or CAPD
MusculoskeletalJoint painMuscle or joint weaknessMuscle pain or crampsBack painCold extremitiesJoint replacementPain while at restArthritisHernia
Integumentary (skin, breast)Rash or itchingChange in skin colorVaricose veinsBreast painBreast lumpBreast discharge
NeurologicalFrequent/recurring headachesLight headed or dizzyConvulsions or seizuresNumbness/tingling sensationTremors
Neurological (cont’d)ParalysisHead injuryStroke (CVA or TIA)Migraine headachesBrain tumor
PsychiatricMemory loss or confusionNervousnessDepressionInsomniaAnxiety
EndocrinePrescription steroid usePituitary diseaseGlandular/hormone problemsExcessive thirst or urinationHeat or cold intoleranceDiabetes
Oral medications InsulinThyroid disease
Hematologic/LymphaticSlow to heal after cutsTendency to bleed or bruiseAnemiaPhlebitis or blood clots in legsBlood or plasma transfusionEnlarged glandsCancerChemo or radiationHIV +
Date & location of most recent bloodwork:
Date & location of most recent EKG:
Date & location of most recent chest X-ray:
Allergy/ImmunologicAllergic rashHivesRecurrent InfectionsSeasonalMedication allergies
(List medication and type of reaction)
Y N
MEDICAL HISTORY AND REVIEW OF SYSTEMS – Please indicate any personal history below, past or present
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Y N
Y NY NY NY N
Y NY NY NY N
Y NY NY NY NY NY N
Y NY NY NY N
Y NY NY N
Y N
Y NY NY NY NY NY N
Y NY NY NY N
Y NY NY N
Y NY NY N
Y NY NY NY NY NY NY NY N
Y NY NY NY N
Y NY NY N
Y NY NY NY N
Y NY NY NY NY NY NY NY NY N
Y NY N
Y NY NY NY NY N
Y NY NY NY NY N
Y NY NY NY N
Y NY NY NY NY NY N
Y N
Y NY NY NY NY NY NY NY NY N
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Y N
Y NY NY NY N
Y N
Last: First: DOB: / /
Atlantic Sports Health111 Madison Avenue, Suite 400, Morristown, NJ89 Sparta Avenue, Suite 205, Sparta, NJ
Page 5 of 7
SURGICAL HISTORY – Please check any surgeries you have had and list when
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Aneurysm
Angioplasty
Appendix
Arthroscopy
Back Surgery
Breast Biopsy
Cataracts
Caeserean Section
Colon
Colonoscopy
Colon Resection
Colostomy/Ileostomy
Endoscopy
Fracture (list please)
Gallbladder
Heart Bypass
Hernia
Hysterectomy
Knee/Hip Replacement
Laparascopy
Lasik Eye Surgery
Mastectomy
Nerve Surgery
Plastic Surgery
Prostate
Rotator Cuff
Skin Cancer
Spine
Thyroid
Tonsil/Adenoids
Total Joints
Tubal Ligation
Vasectomy
/ /
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List any other surgical procedure you have ever had, including approximate date of procedure.
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SOCIAL HISTORY
Use of alcohol: Never Rarely Moderate Daily Drinks/week (hard alcohol, beer, and/or wine)
Use of tobacco: Never Rarely Previously, but quit, when? Currently Packs/day Years
Use of drugs: Never Rarely Previously, but quit, when?
Do you exercise? Yes No # days/week. Please list the types of exercise below:
Last: First: DOB: / /
Atlantic Sports Health111 Madison Avenue, Suite 400, Morristown, NJ89 Sparta Avenue, Suite 205, Sparta, NJ
Page 6 of 7
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FAMILY MEDICAL HISTORY
Name Age Diseases If deceased, cause of death
Father
Mother
Siblings
Spouse
Children
PLEASE LIST YOUR CURRENT MEDICATIONS, VITAMINS AND HERBAL SUPPLEMENTS
Medication Reason for TakingDosage and Times per Day Prescribing Doctor
Office Use Only
Blood Pressure Pulse Temperature Height Weight BMI
/ bpm °F lbs
Date reviewed MD signature
feet inches
/ /
Last: First: DOB: / /
Atlantic Sports Health111 Madison Avenue, Suite 400, Morristown, NJ89 Sparta Avenue, Suite 205, Sparta, NJ
Page 7 of 7
LOCATION AND DIRECTIONS
111 Madison Avenue, Suite 400Morristown, NJ 07960
From the NorthSouth on Rt 287, exit 35 (Madison Ave).Left at traffic light onto Madison Ave.Right into 111 Madison Ave (3rd building on right following 1st traffic light).
From the SouthNorth on Rt. 287, exit 35 (South St.)Left at traffic light onto South St.1st right onto Madison Ave. access roadRight turn at stop sign onto Madison Ave.Right into 111 Madison Ave. (3rd building on right following 1st traffic light).
111 Madison Avenue, Suite 400Morristown, NJ
89 Sparta Avenue, Suite 205Sparta, NJ
89 Sparta Avenue, Suite 205Sparta, NJ 07871
From Newton Medical CenterLeft out of driveway (Route 94 N). Follow Route 94 to Newton town square. Make right at second light onto Spring Street/CR-616. Continue for 6.6 miles (Spring Street turns into Sparta Ave). Building will be on the left, after Sparta Athletic Club.
From Eastern New JerseyTake I-80 West to exit 34B Route 15N Jefferson/Sparta. Continue on 15N for 10.6 miles. Take CR-517 ramp toward Sparta/ Franklin. Turn left at light onto CR-517. Proceed for 8/10 mile. Building will be on the right, after intersection.