CCOMG Medical History – Rev 10/24/12 Page 1 of 4

I. PATIENT IDENTIFICATION

Patient’s Name: Date of

Birth: Today’s

Date:

How were you referred to our office? £ self £ emergency room (which one?)

£ primary care doctor (list name) £ other (list name)

Who is your primary / family doctor? (if different than above)

Which doctor are you here to see today?

Have you seen any other doctors in this office? If so, which?

II. PRESENTING COMPLAINT / PROBLEM

What body part (and which side) are you here to see the doctor about?

Are you: £ right handed £ left handed What is your height? Weight?

Do you have any of the following symptoms?

Pain £ sharp or £ dull £ loss of motion £ locking £ grinding

£ giving way / instability £ numbness £ swelling £ other

Please CHECK any / all limitations associated with your injury:

£ reach overhead / behind £ lift £ bend / twist £ walk £ run £ squat / kneel £ cut / pivot £ other (describe):

Problem Onset: £ gradual £ sudden Date of onset / injury:

If this was an accident or injury, how did it occur?

Did this accident or injury occur at work?

Other doctors you have seen for this problem?

Have you had any previous injury to this part of your body? When?

Please explain the treatment you received (medication, surgeries, etc:)

PLEASE COMPLETE THE REVERSE SIDE OF THIS PAGE BEFORE CONTINUING ON TO THE THIRD PAGE

Because of Governmental requirements that Physicians document complete medical information on each patient, we ask you to complete the following detailed form by filling in the blanks or checking the appropriate boxes. If you have trouble completing it, please feel free to ask any of our staff for assistance. Some of the information may be sensitive. Rest assured that the staff and physicians of Central Coast Orthopedics will keep this information confidential. Thank you for your cooperation.

CENTRAL COAST ORTHOPEDIC MEDICAL GROUP QUESTIONNAIRE

CCOMG Medical History – Rev 10/24/12 Page 2 of 4

IV. MEDICATIONS–PLEASE INCLUDE OVER THE COUNTER MEDICATIONS AND HERBAL SUPPLEMENTS MEDICATION DOSAGE

(mg) # TIMES

PER DAY DATE

STARTED DOCTOR MEDICATION DOSAGE (mg)

# TIMES PER DAY

DATE STARTED DOCTOR

Please list the name and location of the pharmacy you use:

V. SURGERIES – PLEASE LIST

VI. ALLERGIES (DRUG REACTIONS):

Are you allergic to any drugs, or have you had any reactions to medications? £ No £ Yes If yes, LIST the drugs you are allergic to AND the kind of reaction you had:

VII. REVIEW OF SYSTEMS:

CHECK YES or NO to indicate if you have had any of the following disorders, and CIRCLE the appropriate condition:

General: Unexplained weight loss, chills, fever, night sweats, sleep disturbances, depression, headaches £ No £ Yes

Neurological: Difficulty swallowing, speaking, changes in sensation, seizures, balance £ No £ Yes

EENT: Double vision, blurred vision, hearing loss, sinus infections, hoarseness, dizziness, ringing in ears £ No £ Yes

Respiratory: Shortness of breath, chronic cough £ No £ Yes

Cardiovascular: Chest pain, irregular heart beat £ No £ Yes

GI: Appetite, abdominal pain, constipation, diarrhea, vomiting blood, bleeding rectally £ No £ Yes

Urinary: Incontinence, hesitancy, burning, frequency, blood in urine £ No £ Yes

Skin: Color changes, rashes, lesion, masses, ulcers £ No £ Yes

Anything else (please specify): £ No £ Yes

III. MEDICAL HISTORY

CHECK YES or NO to indicate if you have EVER had any of the following disorders, and CIRCLE the appropriate condition:

General: Rheumatoid arthritis, cancer (site) £ No £ Yes

Neurological: Migraine headaches, seizures, epilepsy, stroke, polio £ No £ Yes

Endocrine: Diabetes, thyroid disease £ No £ Yes

Head / Neck: Glaucoma £ No £ Yes

Respiratory: Asthma, emphysema, other lung disease (explain) £ No £ Yes

Cardiac: Heart disease /unspecified, angina/coronary artery disease/MI, arrhythmia, mitral valve prolapse £ No £ Yes

GI/Urinary: Reflux/ulcer disease, liver disease/hepatitis, kidney disease/failure £ No £ Yes

Vascular: High blood pressure, phlebitis/clot, anemia £ No £ Yes

CCOMG Medical History – Rev 10/24/12 Page 3 of 4

VIII. FAMILY HISTORY – Is there a family history of any serious medical condition or atraumatic early death?

£ No £ Yes If yes, please explain:

IX. SOCIAL HISTORY

Occupation: £ Active £ Retired

What athletic activities do you participate in?

Do you £ live alone? or £ live with spouse or friend? or £ live with parents?

Gender: £ male £ female Language: £ English £ Spanish £ Other:

Ethnicity: £ Hispanic £ Non-Hispanic £ Unknown £ Decline to Answer Race: £ American Indian £ Alaskan Native £ Asian £ Black or African-American £ American £ Native Hawaiian £ Other Pacific Islander £ White £ Unknown £ Decline to Answer

Do you £ live in a home setting? or £ an assisted residence facility (which one)?

Alcohol Use: £ None £ Rare £ Social £ Frequent Number of Years?

Smoking History: £ Nonsmoker £ Current Smoker Packs per day Years

£ Previous Smoker How long ago did you quit?

Drug Use: £ No £ Yes What type?

Have you been tested for HIV or hepatitis? £ No £ Yes

If yes, what was the date & the result?

Patient Signature Date

Physician Notes:

I have reviewed this form and used the data in forming my opinion and making my recommendations. Physician’s initials Date Physician’s initials Date Physician’s initials Date Physician’s initials Date

CENTRAL COAST ORTHOPEDIC MEDICAL GROUP QUESTIONNAIRE

CCOMG Medical History – Rev 10/24/12 Page 4 of 4

Definitions of Examinations for E & M Coding

Problem Focused Exam

Expanded Problem Focused

Detailed Problem Focused Comprehensive

History Including chief complaint, brief history of present illness or problem

Including chief complaint, brief history of present illness, problem pertinent system review

Including chief complaint; extended history of present illness; problem pertinent review extended to include a review of a limited number of additional systems; pertinent past, family and/or social history directly related to the patient’s problems

Including chief complaint, extended history of present illness, review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family and social history

Exam Including a limited exam of the affected body area or organ system

Including a limited exam of the affected body area or organ system and other symptomatic or related organ system(s)

Including an extended exam of the affected body area or organ system and other symptomatic or related organ system(s)

Including a general multi-system exam or a complete exam of a single organ system. Please see table below.

Complexity Complexity of medical decision making is straightforward (minimal number of diagnoses or management options, minimal to no amount of data to be reviewed, minimal risk of complications and/or morbidity/mortality)

Complexity of medical decision making is straightforward (see column to the left)

Complexity of medical decision making is of low complexity (limited number of diagnoses or management options, limited amount and/or complexity of data to be reviewed, low risk of complications and/or morbidity/mortality)

Complexity of medical decision making is moderate to high (multiple to extensive number of diagnoses or management options, moderate to extensive amount and/or complexity of data to be reviewed, moderate to high risk of complications and/or morbidity/mortality)

New Pt. Codes 99201 99202 99203 99204-99205 Est. Pt. Codes 99211-99212 99213 99214 99215 Consult Codes 99241 and 99271 99242 and 99272 99243 and 99273

99244-99245 99274-99275

Comprehensive Exam CPT Definitions: For the purpose of CPT definitions, the following body areas are recognized:

For the purpose of CPT definitions, the following organ systems are recognized:

• Head, including the face • Neck • Chest, including breasts and axilla • Abdomen • Genitalia, groin, buttocks • Back • Each extremity

• Eyes • Ears, Nose, Mouth and Throat • Cardiovascular • Respiratory • Genitourinary • Musculoskeletal • Skin Neurologic • Psychiatric • Hematologic / Lymphatic / Immunologic