oklahoma arthritis center · edmond, ok 73013 phone: (405) 844-4978 fax: (405) 844-0562 new patient...

Oklahoma Arthr i t i s Center 1701 S. Renaissance Boulevard, Suite 110

Edmond, OK 73013

Phone: (405) 844-4978 Fax: (405) 844-0562

New Patient Information

Welcome to the Oklahoma Arthritis Center. Thank you for choosing us as partners in your healthcare. Our goal is to provide you with the highest quality medical care available in a convenient setting.

To schedule your appointment, please read, complete, sign, and return the enclosed items:

1. Patient Communication Form 2. Patient History Form 3. Health Assessment Questionnaire 4. Demographic Review Form 5. Front and Back Copy of Insurance Card(s)

Please return the completed forms listed above, prior to scheduling your appointment, by mail or fax as follows:

By mail - 1701 S Renaissance Blvd, Suite 110, Edmond, OK 73013

By fax - (405) 844-0562. Attention: “New Patient Coordinator”

Please arrive at our office 15 minutes prior to your scheduled appointment time.

On the day of your appointment, please bring:

Your current Insurance card(s)

Driver License or State Identification card

Any recent Lab work or X-Ray results.

If you are unable to keep your appointment, please contact our office and speak with a staff member two (2) business days prior to your scheduled appointment.

Should you have any questions, please feel free to contact our New Patient Coordinator at (405) 844-4978,

extension 551.

We look forward to meeting you!

-The Staff at the Oklahoma Arthritis Center


Edmond, OK 73013

Phone: (405) 844-4978 Fax: (405) 844-0562

Helpful Information

Office Hours: Mon. – Thurs. 8:00 a.m. to 4:00 p.m. Friday 8:00 a.m. to 11:00 a.m.

For New Patient Appointment inquiries, call (405) 844-4978, extension 551. If you are unable to keep your

appointment, kindly call us at least two days before your scheduled appointment. We will work with you to

reschedule your appointment to a more convenient time.

If you have questions about your insurance, we will be happy to assist you. Specific coverage issues should be

directed to your insurance company’s member services department, typically located on the back of your insurance

card. Please keep in mind it is the patient’s responsibility to provide us with current insurance information and to

bring insurance card(s) to each visit.

In medical facilities we have many people with allergies and sensitivities, therefore, our clinic is a Fragrance Free

Environment. Please do not wear scents, perfumes or colognes on the day of your appointment.

For prescription refills, please call your pharmacy to request the refill. As an option, Arthritis Pharmacy Solutions

is located in our clinic for your convenience and can be reached at (405) 844-6955. The pharmacy will call our

prescription refill line for authorization to refill the prescription. We require at least 24 hours for the authorization

of the refill. Pain medications cannot be filled early.

Laboratory tests are a routine part of your healthcare. If your provider indicates that you will be contacted

regarding your results, please allow three (3) business days. In most cases, your lab results will be discussed at

your next scheduled appointment.

Phone messages are checked and returned frequently. If you would like to speak with a nurse or provider regarding a medical question, please call us at (405) 844-4978. You may also leave a voice message on the nurses’ line and we will get back to you within 24 hours.

In the event of an emergency, please go to your nearest emergency room.

After your first appointment, if you have an urgent medical need after regular hours of operation, a provider is available to you. To reach the provider on-call, you may call Doctor’s Choice answering service at (405) 631-5335 and they will contact the provider on call. A provider will return your call.


Edmond, OK 73013

Phone: (405) 844-4978 Fax: (405) 844-0562

Directions to Oklahoma Arthritis Center

Take Hwy 77 (Broadway Extension) to 15th Street in Edmond

Turn West onto 15th Street

Go through Kelly Avenue

Take the very first left onto Renaissance Blvd. (There is a large cement marquee at the entrance that says “Renaissance” on it.)

We are the third building on the right with white columns in the front.

Take I-35 to Edmond to 15th Street, Exit 140

Go West 4 miles on 15th Street to Kelly Avenue

Go through Kelly Avenue

Take the very first left onto Renaissance Blvd. (There is a large cement marquee at the entrance that says “Renaissance” on it.)

We are the third building on the right with white columns in the front.

OR:

PATIENT COMMUNICATION CONSENT FORM

Patient: DOB: MRN:

Oklahoma Arthritis Center

FollowMyHealth.com Patient Portal Consent

Oklahoma Arthritis Center is offering a Patient Portal site in partnership with “Follow My Health.” This is a secure web portal that allows you, as a patient, to access and manage not only your medical records at Oklahoma Arthritis Center but with other providers as well. Through the “Follow My Health” Patient Portal you will have access to your medication list, lab results, problem list, scheduled appointments, etc as well as have the option to request appointments.

Please read the following carefully:

DO NOT USE THE PORTAL TO COMMUNICATE AN EMERGENCY CALL 911 or Go to the Emergency Room

We are offering the “Follow My Health” patient portal as a convenience to you at no cost. We do not sell or give away anyprivate information, including e-mail addresses. This is an optional service and we reserve the right to suspend orterminate the patient portal at any time and for any reason.

Your use of this Patient Portal is entirely voluntary and accessing the Patient Portal will not affect the current level orquality of care you receive from Oklahoma Arthritis Center.

You may view scheduled appointments and request appointments. You may view selected health information such as lab results, allergies, medications, current problems, etc. It is YOUR RESPONSIBILITY to notify “Follow My Heath” if there is a change in your e-mail account or if you password

has been compromised. By using this patient portal, you agree to protect your password from any unauthorized individuals. It is YOUR

RESPONSIBILITY to protect your Personal Health Information located on the portal. You agree to not hold Oklahoma Arthritis Center responsible for any network infractions beyond our control. Oklahoma Arthritis Center is in partnership with a third party, “Follow My Health,” to provide selected personal health

information to you. Oklahoma Arthritis Center does not have access to your Patient Portal other than to send informationto it that is contained in your medical record here. Oklahoma Arthritis Center does not have the ability to see your portalinformation or maintain the portal.

Yes, please sign me up for the portal.

If yes, email Address for Portal _______________________________________________________

Last 4-Digits of SSN _________ (this will be used as your security code for registration)

Signature:___________________________________________________ Date:___________________________

Patient’s Name Date

Patient History Form © 1999 American College of Rheumatology

Patient History Form

Date of first appointment: Time of appointment: Birthplace:

Name: Birthdate: / / LAST FIRST MIDDLE INITIAL MAIDEN MONTH DAY YEAR

Address: Age: Sex: F M STREET APT#

Telephone: Home ( ) CITY STATE ZIP Work ( )

MARITAL STATUS: Never Married Married Divorced Separated Widowed

Spouse/Significant Other: Alive/Age Deceased/Age Major Illnesses

EDUCATION (circle highest level attended):

Grade School 7 8 9 10 11 12 College 1 2 3 4 Graduate School

Occupation Number of hours worked/average per week

Referred here by: (check one) Self Family Friend Doctor Other Health Professional

Name of person making referral:

The name of the physician providing your primary medical care:

Do you have an orthopedic surgeon? Yes No If yes, Name:

Describe briefly your present symptoms:

Date symptoms began (approximate):

Diagnosis:______________________________________________

Previous treatment for this problem (include physical therapy, surgery and injections; medications to be listed later)

Please list the names of other practitioners you have seen for this problem:

RHEUMATOLOGIC (ARTHRITIS) HISTORY

At any time have you or a blood relative had any of the following? (check if “yes”) Yourself Relative

Name/Relationship Yourself Relative

Name/Relationship

Arthritis (unknown type) Lupus or “SLE”

Osteoarthritis Rheumatoid Arthritis

Gout Ankylosing Spondylitis

Childhood arthritis Osteoporosis

Other arthritis conditions:

Example

Example:

Adapted from CLINHAQ, Wolfe F and Pincus T. Current Comment – Listening to the patient – A practical guide to self report questionnaires in clinical care. Arthritis Rheum. 1999;42 (9):1797-808. Used by permission.

Please shade all the locations of your pain over the past week on the body figures and hands.



SYSTEMS REVIEW

As you review the following list, please check any of those problems, which have significantly affected you.

Date of last mammogram / / Date of last eye exam / / Date of last chest x–ray / /

Date of last Tuberculosis Test / / Date of last bone densitometry / /

Constitutional Recent weight gain

amount Recent weight loss

amount Fatigue Weakness Fever

Eyes Pain Redness Loss of vision Double or blurred vision Dryness Feels like something in eye Itching eyes

Ears–Nose–Mouth–Throat Ringing in ears Loss of hearing Nosebleeds Loss of smell Dryness in nose Runny nose Sore tongue Bleeding gums Sores in mouth Loss of taste Dryness of mouth Frequent sore throats Hoarseness Difficulty in swallowing

Cardiovascular Pain in chest Irregular heart beat Sudden changes in heart beat High blood pressure Heart murmurs

Respiratory Shortness of breath Difficulty in breathing at night Swollen legs or feet Cough Coughing of blood Wheezing (asthma)

Gastrointestinal Nausea Vomiting of blood or coffee ground material Stomach pain relieved by food or milk Jaundice Increasing constipation Persistent diarrhea Blood in stools Black stools Heartburn

Genitourinary Difficult urination Pain or burning on urination Blood in urine Cloudy, “smoky” urine Pus in urine Discharge from penis/vagina Getting up at night to pass urine Vaginal dryness Rash/ulcers Sexual difficulties Prostate trouble

For Women Only: Age when periods began: Periods regular? Yes No How many days apart? Date of last period? / / / Date of last pap? / / Bleeding after menopause? Yes No Number of pregnancies? Number of miscarriages? Musculoskeletal

Morning stiffness Lasting how long?

Minutes Hours Joint pain Muscle weakness Muscle tenderness Joint swelling List joints affected in the last 6 mos.

Integumentary (skin and/or breast) Easy bruising Redness Rash Hives Sun sensitive (sun allergy) Tightness Nodules/bumps Hair loss Color changes of hands or feet in the cold

Neurological System Headaches Dizziness Fainting Muscle spasm Loss of consciousness Sensitivity or pain of hands and/or feet Memory loss Night sweats

Psychiatric Excessive worries Anxiety Easily losing temper Depression Agitation Difficulty falling asleep Difficulty staying asleep

Endocrine Excessive thirst

Hematologic/Lymphatic Swollen glands Tender glands Anemia Bleeding tendency Transfusion/when

Allergic/Immunologic Frequent sneezing Increased susceptibility to infection



SOCIAL HISTORY

Do you drink caffeinated beverages?

Cups/glasses per day?

Do you smoke? Yes No Past – How long ago?

Do you drink alcohol? Yes No Number per week

Has anyone ever told you to cut down on your drinking?

Yes No

Do you use drugs for reasons that are not medical? Yes No If yes, please list:

Do you exercise regularly? Yes No

Type

Amount per week

How many hours of sleep do you get at night?

Do you get enough sleep at night? Yes No

Do you wake up feeling rested? Yes No

PAST MEDICAL HISTORY Do you now or have you ever had: (check if “yes”)

Cancer Heart problems Asthma

Goiter Leukemia Stroke

Cataracts Diabetes Epilepsy

Nervous breakdown Stomach ulcers Rheumatic fever

Bad headaches Jaundice Colitis

Kidney disease Pneumonia Psoriasis

Anemia HIV/AIDS High Blood Pressure

Emphysema Glaucoma Tuberculosis

Other significant illness (please list)

Natural or Alternative Therapies (chiropractic, magnets, massage, over-the-counter preparations, etc.)

___________________________________________________________

_____________________________________________________

_____________________________________________________

Previous Operations

Type Year Reason

1.

2.

3.

4.

5.

6.

7.

Any previous fractures? No Yes Describe:

Any other serious injuries? No Yes Describe:

FAMILY HISTORY:

IF LIVING IF DECEASED

Age Health Age at Death Cause

Father

Mother

Number of siblings Number living Number deceased

Number of children Number living Number deceased List ages of each

Health of children:

Do you know of any blood relative who has or had: (check and give relationship)

Cancer

Leukemia

Heart disease

High blood pressure

Rheumatic fever

Epilepsy

Tuberculosis

Diabetes

Stroke

Colitis

Bleeding tendency

Alcoholism

Asthma

Psoriasis

Goiter



MEDICATIONS Drug allergies: No Yes To what?

Type of reaction:

PRESENT MEDICATIONS (List any medications you are taking. Include such items as aspirin, vitamins, laxatives, calcium and other supplements, etc.)

Name of Drug Dose (include strength & number of

pills per day)

How long have you taken this

medication

Please check: Helped? A Lot Some Not At All

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

PAST MEDICATIONS Please review this list of “arthritis” medications. As accurately as possible, try to remember which medications you have taken, how long you were taking the medication, the results of taking the medication and list any reactions you may have had. Record your comments in the spaces provided.

Drug names/Dosage Length of time

Please check: Helped? A Lot Some Not At All

Reactions

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Circle any you have taken in the past Ansaid (flurbiprofen) Arthrotec (diclofenac + misoprostil) Aspirin (including coated aspirin) Celebrex (celecoxib) Clinoril (sulindac)

Daypro (oxaprozin) Disalcid (salsalate) Dolobid (diflunisal) Feldene (piroxicam) Indocin (indomethacin) Lodine (etodolac)

Meclomen (meclofenamate) Motrin/Rufen (ibuprofen) Nalfon (fenoprofen) Naprosyn (naproxen) Oruvail (ketoprofen)

Tolectin (tolmetin) Trilisate (choline magnesium trisalicylate) Vioxx (rofecoxib) Voltaren (diclofenac)

Pain Relievers Acetaminophen (Tylenol) Codeine (Vicodin, Tylenol 3) Propoxyphene (Darvon/Darvocet) Other: Other:

Disease Modifying Antirheumatic Drugs (DMARDS) Auranofin, gold pills (Ridaura) Gold shots (Myochrysine or Solganol) Hydroxychloroquine (Plaquenil) Penicillamine (Cuprimine or Depen) Methotrexate (Rheumatrex) Azathioprine (Imuran) Sulfasalazine (Azulfidine) Quinacrine (Atabrine) Cyclophosphamide (Cytoxan) Cyclosporine A (Sandimmune or Neoral) Etanercept (Enbrel) Infliximab (Remicade) Prosorba Column Other: Other:



PAST MEDICATIONS Continued

Osteoporosis Medications Estrogen (Premarin, etc.) Alendronate (Fosamax) Etidronate (Didronel) Raloxifene (Evista) Fluoride Calcitonin injection or nasal (Miacalcin, Calcimar) Risedronate (Actonel) Other: Other:

Gout Medications Probenecid (Benemid) Colchicine Allopurinol (Zyloprim/Lopurin) Other: Other:

Others Tamoxifen (Nolvadex) Tiludronate (Skelid) Cortisone/Prednisone Hyalgan/Synvisc injections Herbal or Nutritional Supplements

Please list supplements:

Have you participated in any clinical trials for new medications? Yes No

If yes, list:



ACTIVITIES OF DAILY LIVING

Do you have stairs to climb? Yes No If yes, how many?

How many people in household? Relationship and age of each

Who does most of the housework? Who does most of the shopping? Who does most of the yard work?

On the scale below, circle a number which best describes your situation; Most of the time, I function…

1 2 3 4 5

VERY POORLY OK WELL VERY POORLY WELL

Because of health problems, do you have difficulty: (Please check the appropriate response for each question.)

Usually Sometimes No

Using your hands to grasp small objects? (buttons, toothbrush, pencil, etc.)........................................................

Walking? ...............................................................................................................................................................

Climbing stairs?.....................................................................................................................................................

Descending stairs?................................................................................................................................................

Sitting down?.........................................................................................................................................................

Getting up from chair?...........................................................................................................................................

Touching your feet while seated?..........................................................................................................................

Reaching behind your back?.................................................................................................................................

Reaching behind your head? ................................................................................................................................

Dressing yourself? ................................................................................................................................................

Going to sleep?.....................................................................................................................................................

Staying asleep due to pain?..................................................................................................................................

Obtaining restful sleep? ........................................................................................................................................

Bathing?................................................................................................................................................................

Eating?..................................................................................................................................................................

Working?...............................................................................................................................................................

Getting along with family members? .....................................................................................................................

In your sexual relationship? ..................................................................................................................................

Engaging in leisure time activities? .......................................................................................................................

With morning stiffness?.........................................................................................................................................

Do you use a cane, crutches, as walker or a wheelchair? (circle one)..................................................................

What is the hardest thing for you to do?

Are you receiving disability?...............................................................................................................................Yes No

Are you applying for disability?...........................................................................................................................Yes No

Do you have a medically related lawsuit pending?.............................................................................................Yes No

Health Assessment QuestionnaireStanford University School of Medicine – Division of Immunology & Rheumatology

Name _________________________________ Date _________________________

Please check the response that best describes your usual abilitiesOVER THE PAST WEEK:

DRESSING & GROOMING

Are you able to: - Dress yourself, including tying shoelaces and doing buttons?

- Shampoo your hair?

ARISING

Are you able to: - Stand up from a straight chair?

- Get in and out of bed?

EATING

Are you able to: - Cut your meat?

- Lift a full cup or glass to your mouth?

- Open a new milk carton?

WALKING

Are you able to: - Walk outdoors on flat ground?

- Climb up five (5) steps?

Please check any AIDS OR DEVICES that you usually use for any of these activities: Cane Built-up or special utensils Special or built up chair Wheelchair

Crutches Devices used for dressing Walker

Other (specify:) _______________________________________________________________

Please check any categories for which you usually need HELP FROM ANOTHER PERSON:

Arising Eating Walking Dressing and grooming

(FOR OFFICEUSE ONLY)

HIGHESTSCORE

Please check the response that best describes your usual abilitiesOVER THE PAST WEEK:

HYGIENE

Are you able to: - Wash and dry your body?

- Take a tub bath?

- Get on and off the toilet

REACH

Are you able to: - Get down a 5-pound object (like a bag of sugar) from just above your head?

- Bend down to pick up clothing from the floor?

GRIP

Are you able to: - Open a car door?

- Open Jars which have been previously opened?

- Turn faucets on and off?

ACTIVITIES

Are you able to: - Run errands and shop?

- Get in and out of the car?

- Do chores such as vacuuming or yard work?

Please check any AIDS OR DEVICES that you usually use for any of these activities: Raised toilet seat Long-handled tool for bathroom Bathtub bar

Bathtub seat Long-handled tool for reach Other (specify :) Toilet grip bar Jar opener (for jars previously opened ) __________________________

Please check any categories for which you usually need HELP FROM ANOTHER PERSON: Hygiene Reach Gripping and opening things Errands and chores

Place a vertical (l) mark on the line to indicate the severity of pain due to your illness:

(FOR OFFICEUSE ONLY)

HIGHESTSCORE

TOTAL÷

Number ofanswered groups

=

TOTAL HAQDISABILITY

SCORE

TOTAL PAINSCORE

No Pain Severe Pain____________|____________|____________|____________|____________|____________|____________|____________|____________|____________

0 10

DEMOGRAPHIC INFORMATION

Oklahoma Arthritis Center, P.C. 1701 S. Renaissance Blvd. #110 Edmond, Oklahoma 73013 Phone: 405-844-4978 Fax: 405-844-0562 Patient Information

Name DOB SSN Marital Status

Address City State Zip

Home Phone Cell Phone Work Phone E-Mail

Preferred Method of Contact: Phone E-Mail Text Message Employer Referring Physician Primary Care Physician

Insurance Primary Insurance Member ID # Group #

Insurance Claims Address Insurance Claims Contact Number

Policy Holder Policy Holder SSN DOB Self Spouse Parent

Secondary Insurance Secondary Member ID # Secondary Group #

Secondary Insurance Policy Holder Policy Holder SSN DOB Self Spouse Parent

Secondary Claims Address Secondary Claims Contact Number

Emergency Contact Name Relationship Phone

Check here to Allow disclosure of protected health information to your emergency contact

Demographics Gender Date of Birth

Rac

e

American Indian/Alaskan Native Native Hawaiian or Other Pacific Islander

Asian White

Black or African American Do Not Report

Eth

nici

ty

Hispanic or Latino

Not Hispanic or Latino

Do Not Report Preferred Language

Permission of Disclosure of Protected Health Information (Optional)

I, «PName» authorize Oklahoma Arthritis Center to disclose my health information to the persons listed below. This information may include, appointment times or changes, test results, medications, doctor and/or nurse reports, or any other information this office has about me. I also authorize Oklahoma Arthritis Center to leave telephone messages regarding appointment times or changes, test results, medications, doctor and/or nurse reports, requests to return calls, financial account information, or any other information this office has about me.

Please check this box if you DO NOT want messages left on your telephone

Name Relationship Name Relationship

______________________________ ____________ ______________________________ ____________ __

______________________________ ____________ ______________________________ ____________ __ By Oklahoma law, we are required to notify you that the information authorized for release may include records which may indicate the presence of a communicable or venereal disease which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea, and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS).

Notice of Privacy Practices By signing below, I acknowledge receipt of Oklahoma Arthritis Center’s “Notice of Privacy Practices.” I also authorize the release of medical information required to process all claims on my behalf. I also authorize payment of insurance benefits from those claims be made payable to Oklahoma Arthritis Center. I understand I am financially responsible for any charge not covered by my insurance. X__________________________________________________ _________________________________________________

Patient or Authorized Person Signature Date OAC Staff Signature Date

oklahoma arthritis center · edmond, ok 73013 phone: (405) 844-4978 fax: (405) 844-0562 new patient...

Documents