Red * Fields Required.
 
 Male     
 Female 
  Age:
 Single    
 Divorced     
 Widowed     
 Married 
- -







 Yes   
 No 
 
 Yes   
 No 
 
 Better   
 Worse   
 Same 
 
  
 English 
 Non-English   
 Decline to Answer   
  
 English   
 Non-English   
 Decline to Answer 
  
 English   
 Non-English   
 Decline to Answer 
 American Indian or Alaska Native   
 Asian   
 African American   
 Native Hawaiian or Other Pacific Islander   
 Caucasian   
 Unknown   
 Decline to Answer 
 Hispanic or Latino   
 Not Hispanic or Latino   
 Unknown   
 Decline to Answer 

Insurance Information

Primary Insurance

  Age:

Secondary Insurance

  Age:

Other Insurance

Medical History

 Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 
     Yes     No 

Review of Systems

 
 None  
 Recent weight change  
 Chills  
 Fever  
 Weakness/Fatigue  
 Other
 
 
 None  
 Vision Change  
 Glasses/contacts  
 Cataracts  
 Glaucoma  
 Other
 
 
 None  
 Hearing Loss  
 Ear Ache  
 Ringing in ear  
 Other
 
 
 None  
 Chest pain  
 Swelling in legs   
 Palpitations  
 Other
 
 
 None  
 Shortness of Breath  
 Wheezing, Asthma  
 Frequent Cough  
 Other
 
 
 None  
 Acid Reflux  
 Nausea or Vomiting  
 Abdominal Pain  
 Other
 
 
 None  
 Muscle Aches  
 Swelling of the Joints  
 Stiffness in Joints  
 Other
 
 
 None  
 Rash  
 Ulcers  
 Abnormal scars  
 Other
 
 
 None  
 Headaches  
 Dizziness  
 Numbness/tingling  
 Loss of sensation   
 Other
 
 
 None  
 Depression  
 Nervousness  
 Anxiety  
 Mood Swings  
 Other
 
 
 None  
 Excessive thirst or hunger  
 Hot/Cold intolerance  
 Hot flashes  
 Other
 
 
 None  
 Easy Bruising  
 Easy Bleeding  
 Anemia  
 Other
 

Medical Release and Assignment

I hereby authorize Greater Michigan Orthopedics to release any information regarding my diagnosis and treatment to above stated insurance co, workman's comp carrier and/or physician. I request and authorize payment of medical benefits to Greater Michigan Orthopedics or the providing physician. I also release my medical records to the above named insurance companies, referring physician and myself upon request. If payment is not received within a reasonable length of time, the bill will then become my responsibility. I agree that if I carry an insurance that requires a referral (HMO), I will be responsible to obtain a referral from my primary care physician. I agree if I do not carry health insurance, I am responsible for all services rendered by the treating physician.

We will collect your signature in the office.

If you want your medical information to be released to someone in your family, please list their name(s) below. If their name is not written below, information will not be released.

Medicare Patients

I request the payment of authorized Medicare benefits be made on my behalf to Greater Michigan Orthopedics for any services by that physician/clinic. I authorize any holder of hospital or medical information about me to release to the Healthcare Financing Administration and its agents any information needed to determine the benefits payable for related services. I permit a copy of this authorization be used in place of the original.

We will collect your signature in the office.

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