New Patient Intake - UNM Hospitals

Phone: 505.272.2231Fax: 505.272.8098Mailing address:Department of OrthopaedicsMSC 10-56001 University of NMABQ, NM 87131Appointments will onlybe scheduled once all requiredinformation is received.Orthopaedic Clinics2211 Lomas Blvd NE, 871061101 – 5 Medical Arts Blvd., 871021213 University Blvd., 87102Adult Orthopaedic Referral Sheet for PatientsPATIENT INFORMATIONName Date of Birth UNMH MRNAddress Phone # Work #ORTHOPAEDIC SURGEONSAndrew Paterson, MD Andrew Veitch, MDAntony Kallur, MD Atlee Benally, MDChristopher Hanosh, MD Christopher McGrew, MDDaniel Wascher, MD Deanna Mercer, MDElizabeth Mikola, MD Eric Benson, MDGehron Treme, MD Moheb Moneim, MDPaul Echols, MD Tasheem Cheema, MDThomas DeCoster, MD Richard Miller, MDRick Gehlert, MD Robert Schenck, MDCity/State/Zip CodeSSNInsurancePlease contact yourInsurance for priorauthorizationbefore yourappointment.Patient is untimelyresponsible for thebill.Self-PayPlease Note:We are notcontracted withPres SCIPres SeniorPresEmployeesBeech StreetAmerigroup*Contact clinicfor full list.Primary Insurance:NameAddressPolicy Holder:NameDOBID#Group#Secondary Insurance:NameAddressPolicy Holder:NameDOBID#Group#NameREFERRING PROVIDER/PRIMARY CARE PHYSICIAN INFORMATIONOffice ContactAddress Phone #City/State/Zip Code Fax #Organization NamePCPREASON FOR VISITAll referrals MUST include: 1) Completed referral sheet including insurance information 2) Last clinical notes related todiagnosis 3) Diagnostic test results completed within the last 6 monthsPLEASE SEE BELOW FOR REQUIRED DIAGNOSIC STUDIES DEPENDENT ON DIAGNOSISBack/Neck Pain:MRIJoint Revision:`MRIHand and Microsurgery:RadiographsFractures:RadiographsCarpal Tunnel Syndrome:EMGFoot and Ankle:RadiographsPodiatry:Spine Fracture:CT of Spine withoutContrastSports Medicine :Radiographs and orMRI**ORTHOPAEDICS DOES NOT MANAGE CHRONIC PAINOR PRESCRIBE PAIN MEDICATION TO NON-SURGICAL PATIENTS**PreviousOrthopaedicOperationOperative NotesAppointment Information: _____________at ______________ with Dr. ________________________Location_____________________.PATIENT MUST BRING FILMS/DISCS TO APPT.

MRN ______________Patient Name: __________________________ DOB:___________________Date of Injury __________ On-The-Job Injury Auto Accident Sports InjuryOther __________________________Is there (or will there be) an attorney involved with this problem? Yes NoReason for Visit (Describe problem/injury/symptoms) (Right or Left side?) ________________________________________________________________________________________________Previous Treatment for this Problem(If none, skip to next section)Physicians/Providers Seen: __________________Arthrogram Date________ Facility____________Bone Scan Date________ Facility____________Casting/SplintingDate _________ Facility_____________Chiropractic/AcupunctureDate _________ Facility_____________EMG/Nerve StudyDate _________ Facility_____________Injection Date _________ Facility_____________MRIDate _________ Facility ____________Physical TherapyDate _________ Facility ____________Vascular StudiesDate _________ Facility ____________X-Rays Date _________ Facility ____________Other Date _________ Explain ______________________________________________________Aggravating Factors:Makes the problem/pain worse?BendingDeep BreathDirect PressureExerciseLiftingMovement of AreaWalkingWeight BearingGraspingOther ____________Type of PainAching Numbness Pins & NeedlesBurning Stabbing SevereDescribe the severity of the pain:0= None /10=Worst0 1 2 3 4 5 6 7 8 9 10Where are your symptoms now?Mark the location of your pain on the picturebelow. Place an X over the area of your pain.Relieving Factors:Makes the problem/pain better?Acetaminophen/Tylenol Muscle RelaxantsAnti-Inflammatory/Ibuprofen Prescription PainAspirinMedicationPhysical TherapyRestCrutchesSlingElastic Wrap Compression HeatIceOther____________________________