Dallashipandkneesurgery.com

Kurt W. Rathjen, M. D.
Patient Registration Form
PATIENT INFORMATION
Patient’s Name:________________________________________________________ Sex: M F Marital Status:_________________
SS#____________________________________ DOB__________________________________ Age____________________________ Home Address:______________________________________________________________________________________________________ Home Phone: (____)_____________________ Work Phone: (____)______________________ Fax:(____)__________________________ Cell Phone: (____)_______________________ E-Mail: _________________________________________________________ Employed: Full Part-time Name of Employer: _________________________________________________________________________
Student: Full Part-time Name of School: ____________________________________________________________________________
PARENTAL INFORMATION FOR MINORS (for patients under the age of 18)
Mother’s Name:_________________________________________ Father’s Name:______________________________________________ Mother’s Date of Birth: _______________ SS#_______________ Father’s Date of Birth: _________________ SS#_________________ FAMILY PHYSICIAN
Name: _____________________________________________ Phone No.: _____________________________________________ Address: _________________________________________________________________________________________________________ WHO SENT YOU TO OUR OFFICE
Name: _____________________________________________ Phone No.: _____________________________________________ Address: _________________________________________________________________________________________________________ EMERGENCY CONTACT- Name of relative or friend not living at your address to contact in case of emergency:
Name: _______________________________________________ Phone No.: ______________________________________________ Address: ___________________________________________________________________________________________________________ Kurt W. Rathjen, M.D.
Health History Questionnaire
Please print, answer all questions and sign where indicated
Patient’s Name:____________________________________________ Date of injury/onset of problem:____________________________ Indicated body part(s) affected: _________________________________________________________________________________________ Please describe your injury or problem: __________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Was this an automobile accident? Yes No
Were you injured on the job? Yes No
MEDICATION HISTORY
ALLERGIES: PLEASE CIRCLE ALL THAT APPLY
ARE YOU ALLERGIC TO ANY METAL OR JEWELRY? _______________________________________________________ Please list all medications you are currently taking, REMEMBER to include vitamins, herbs, minerals, & antibiotics
Current Medications
Frequency
Current Medications
Frequency
PAST MEDICAL HISTORY - Please circle any current or past illnesses
Cancer (specify) __________________________ Other _______________________________________ PAST SURGICAL HISTORY - Please circle all that apply
Neck surgery Fracture Repair (specify site) ______________________________________________ Total Hip or Partial Hip Replacement: R L Total Knee Replacement: R L
Other: ____________________________________________________________________________________________________________ FAMILY HISTORY – Please circle all that apply or fill in blanks
Father: Age if living _________ Deceased at age _________ Mother: Age if living _________ Deceased at age _________ Is there a family history of: (Please circle Yes or No)
Diabetes Yes No
High Blood Pressure Yes No
Sudden Unexplained Death Yes No
Asthma Yes No
Arthritis Yes No
SOCIAL HISTORY - Please circle or fill in blanks
Occupation: _________________________________________ Highest level of Education completed: _____________________ Alcohol: Number of drinks per week ___________ Smoking: Number of Packs per day _____________ for _________ years Quit smoking on or about ________________ Smoked # packs/day_________ for _________ years Illicit Drug Use: ___________________________________________ REVIEW OF SYSTEMS: (Please mark all that have occurred in the past year)
CONSTITUTIONAL
EYE & VISION
EARS & HEARING
NOSE & THROAT
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
NEUROLOGIC
PSYCHIATRIC
SKIN & BREAST
ENDOCRINE
HEMATOLOGIC/
ALLERGIC/
LYMPHATIC
IMMUNOLOGIC
To my knowledge the above information is correct. I give my consent for treatment for this illness or injury described herein and I understand that I am financially responsible to
Kurt W. Rathjen, M.D. for all charges not covered by any and all insurances. Payment is expected at the time services are rendered. I understand that both parents of a minor
patient may be asked to sign a statement of financial responsibility. I authorize payment directly to Kurt W. Rathjen, M.D. of any insurance policy benefits payable to me,
and I herby assign all such policy benefits to Kurt W. Rathjen, M.D.
________________________________________________________________________________________________________________________________________________
PATIENT’S SIGNATURE
SIGNATURE OF ADDITIONAL RESPONSIBLE PARTY

Source: http://www.dallashipandkneesurgery.com/pdf%20files/pt%20forms/pt_registration.pdf