Atlantic Prosthetics & Orthotics - Patient Demographics Form
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1Atlantic Prosthetics & Orthotics – Patient Demographics Form
Patient Name: ____________________________________________________________ Male ____ Female____
Date of Birth: ___________________________________ Social Security# ________________________________
Address: __________________________________________City: ____________________State: ____________
Zip code: _____________Marital Status: _______________________ Would you like your bills by: ___Mail ___Email
Home Phone: ___________________________ Cell: _______________________ Work: _____________________
Email Address: __________________________________ Driver License #: _______________________________
Parent or Responsible Party (if patient is a child): ______________________________________________________
Address (if different from above): _________________________________________________________________
Emergency Contact: __________________________________ Phone Number: ____________________________
Are you currently living in a Skilled Nursing Facility? __Yes __ No -Anticipated discharge date: ___________
Medical Information
Weight: ________ Height: ________ Accident date: ____________
State Accident Occurred in: _________
Amputation date: ______________
Referring Physician: __________________________________ Phone Number: ______________________
Primary Physician: ___________________________________ Phone Number: ______________________
Physician that monitors your Diabetes: ______________________________________________________
Have you had an orthopedic device, shoes, brace, or prosthesis in the last 3 years?
___ Yes ___ No
If yes how long have you had the brace? ___________________________
What is the primary reason/ diagnosis for the device you have been prescribed: _____________________
Please check any conditions that apply to you
Diabetes
Hepatitis C
Seizure Disorder
o
o
o
Hypertension
HIV Positive
Hearing Loss
o
o
o
Vascular Disease
Rheumatoid Arthritis
Vision Problems
o
o
o
Stroke
Osteoarthritis
MRSA
o
o
o
Heart Problems
Pulmonary Disease
Currently Pregnant
o
o
o
Kidney Disease
Parkinson Disease
Gout
o
o
o
Osteoporosis
Alzheimer Disease
Gangrene
o
o
o
Hepatitis A or B
Pacemaker
Edema __Upper __Lower
o
o
o
Other Health Conditions: _____________________________________________________________________
Are you currently employed? ___yes ___no
How many hours a day are you on your feet? ________
Do you have a history or ulcers? ___yes ___no Where are your ulcers? __________________________
We will verify your insurance for the device prescribed by your physician and advise you of coverage and any financial responsibility
you may have, We cannot guarantee the benefits we quote to you as the insurance companies do not guarantee the benefits they
quote to us on your behalf. Please refer to your insurance benefits handbook or call your insurance company for more information.
Signature: _________________________________________________________________ Date: ______________
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Parent category: Medical