Patient Intake Form Orthopedic Specialty Institute Page 4
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42) Can
y ou
w alk
w ithout
u sing
s upports
( brace,
c rutches,
c ane,
e tc.)?
Yes
No
3) Can
y ou
w alk
w ithout
a
l imp?
Yes
No
4) Can
y ou
w alk
w ithout
y our
k nee
l ocking
o r
c atching?
Yes
No
5) Can
y ou
w alk
u p
o ne
f light
o f
s tairs?
Yes
No
6) Can
y ou
w alk
u p
f ive
f lights
o f
s tairs?
Yes
No
7) Can
y ou
r un
t he
l ength
o f
o ne
b lock?
Yes
No
8) Can
y ou
r un
o ne
m ile?
Yes
No
9) Does
y our
k nee
a llow
y ou
t o
p ivot,
c hange
d irections,
o r
j ump
w ithout
“giving
w ay”?
Yes
No
10) Does
y our
k nee
a llow
y ou
t o
p erform
y our
n ormal
a ctivities
o f
d aily
l iving
(other
t han
w ork
o r
s port)?
Yes
No
11) Does
y our
k nee
a llow
y ou
t o
p articipate
i n
s ports?
Yes
No
12) Can
y ou
p articipate
i n
s ports
a t
t he
l evel
o f
c ompetition
y ou
d esire?
Yes
No
13) Does
y our
k nee
a llow
y ou
t o
w ork
f ull-‐time
a t
y our
j ob?
Yes
No
20) Do
y ou
e ver
h ave
a ny
o f
t hese
a dditional
s ymptoms?
YES
NO
If
y es,
d escribe
Stiffness
Numbness
Swelling
_
Instability
Weakness
Painful
Roughness
Other
21) Have
y ou
t ried
a ny
o f
t he
b elow?
R elief
o f
S ymptoms?
YES
NO
Medication
Type:
Physical
T herapy
If
y es,
h ow
l ong
d id
y ou
a ttend?
When
w as
y our
l ast
s ession?
Injections
If
y es,
l ocation
&
m edication?
Other
Describe:
I
a cknowledge
t hat
I
h ave
r eceived
t he
N otice
o f
P rivacy
P ractices
o f
t he
O rthopedic
S pecialty
I nstitute
( tri-‐
fold
p amphlet),
w hich
e xplains
i ts
l egal
d uties
a nd
p rivacy
p ractices
w ith
r espect
t o
m y
p rotected
h ealth
i nformation.
By
s igning
b elow,
I
a gree
t hat
a ll
t he
i nformation
p rovided
i s
t rue
t o
t he
b est
o f
m y
k nowledge.
I
a lso
h ereby
authorize
m y
i nsurance
b enefits
b e
p aid
d irectly
t o
t he
p hysician
a nd
I
a m
f inancially
r esponsible
f or
t he
n oncovered
services.
I
a lso
a uthorize
t he
p hysician
t o
r elease
a ny
i nformation
r equired
t o
p rocess
t his
c laim.
Patient
S ignature
Date
I
h ave
r eviewed
t he
a bove
i nformation
i n
d etail
w ith
t he
p atient.
Physician
S ignature
Date
Jeffrey
R .
L yman,
M D
Thomas
H alvorson,
M D
Kate
K uhlman-‐Wood,
M D
Patient
N ame:
Page
4
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