PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number

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1 PATIENT INFORMATION PATIENT NAME Last First M.I. Social Security Number ADDRESS Street DATE OF BIRTH SEX Female Male City State Zip Home Phone Cell Phone Work Phone Marital Status Single Widowed Divorced Married PREFERRED METHOD OF CONTACT Home Phone Cell Phone Work Phone RACE African American Asian Hispanic Caucasian Native American Other EMPLOYER PATIENTS OCCUPATION ETHNICITY Hispanic Non-Hispanic PHARMACY NAME PHARMACY PHONE HOW DID YOU HEAR ABOUT US NAME Community Event LOS Patient/Friend/Family Employer High School/Sport Hospital/Urgent Care Insurance Magazine or Newspaper Physician Radio or Television Website or Online PERSON RESPONSIBLE FOR CHARGES SOCIAL SECURITY NUMBER ADDRESS Street DATE OF BIRTH City State Zip CONTACT PHONE NO. EMPLOYER EMPLOYER PHONE NO. If this is a job related injury, is this the employer you were working for at the time of injury? Yes No If due to an injury, date of loss: / / Will an attorney or Liability Carrier be involved in payment of charges? Yes No If yes, please explain: Is injury related to: Accident Job Related Other: If job related: Claim # Case Manager: Phone No. PRIMARY CARE PHYSICIAN REFERRAL INFORMATION NAME OF REFERRING PHYSICIAN EMERGENCY INFORMATION IN CASE OF EMERGENCY NOTIFY NAME RELATIONSHIP PHONE NO. Revised: 7/2017 ADDRESS Street City State Zip PRIMARY Insured Name: Insured DOB: Insurance Name: Policy ID #: Group/Account #: Social Security #: Relation to Patient: INSURANCE INFORMATION SECONDARY Insured Name: Insured DOB: Insurance Name: Policy ID #: Group/Account #: Social Security #: Relation to Patient: I hereby certify the above information is true and correct to the best of my knowledge. I understand that while LOS contracts with many insurance companies, it is my responsibility to verify with my plan that LOS is a participating provider. It is also my responsibility to find out what my coverage options are with my insurance plan. I hereby authorize LOS to submit insurance claim forms along with medical records necessary to obtain payment from my insurance company. I understand that I am responsible for all charges regardless of my insurance coverage. I acknowledge that photo IDs taken are used to assist in patient recognition per HIPPA guideline. Patient Signature: Date:

2 Financial Policy Louisiana Orthopaedic Specialists ( LOS ) places its patients needs first; however, we must be financially responsible to continue to serve. I understand that it is my responsibility to know my insurance benefits and plan coverage. My insurance may or may not cover the services provided at LOS. To obtain the most accurate information, please check with your insurance carrier to discuss the benefits provided by your medical plan prior to your visit to fully understand your anticipated out of pocket costs. I understand that co-payments, deductibles, co-insurance and non-covered services are to be paid at or before the time of service. LOS accepts cash, checks, major credit cards, debit cards, HSA/FSA and Care Credit. You may also pay your bill online from the Patient/Bill Payment section of our website. I understand that I may be contacted by the telephone regarding my outstanding balance with LOS. I understand that if I do not have my insurance and, referral, and/or co-payment, that my appointment may be rescheduled until such time that I can provide the required documents or payments. I understand that LOS will collect, prior to any surgery or procedure, deductibles and coinsurance up to an amount equal to payment in full for the planned surgical procedure. Surgeries will include Physician Assist fees that will be billed after your surgery. Payment in full and expected coinsurance payment responsibility are determined by the anticipated surgical billing code(s), details of your insurance policy, and agreement between your insurance company and LOS. If the full deductible is not applied to your claim by your insurance company, LOS will refund any overpayment to you when we receive overpayment. I understand if my account has a patient responsibility amount that is not paid in full within 90 days then my account may be placed with an outside collection agency. No additional appointments will be made for delinquent accounts until they are brought current unless the appointment is of an urgent nature. I understand that a $35 service fee will be added for any checks returned for any reason and I will be responsible for payment of this fee and the amount of the returned check. Non-Sufficient Fund checks must be redeemed with certified funds (credit card or cash). I understand that I have until 5 p.m. the day before my appointment to cancel or reschedule. If I do not show up for my appointment and did not cancel in time, a $40 no-show fee will be charged to my account. I understand that there may be fees associated with medical records requests and completion of forms by a physician. I understand that I may be responsible for these fees. Statement of Financial Responsibility: I acknowledge that I am responsible for all charges for services provided, including any amount not paid by my insurance plan(s). This also applies if I am covered by Medicare, a health maintenance organization (HMO), or any other payer. I have read and I understand the above Financial Policy and I agree to abide by its terms. Patient or Guarantor Name: Relationship: Patient Signature: Date: Rev 7/2017

3 Privacy and Disclosure Statement Your treatment, payment, enrollment or eligibility for benefits at Louisiana Orthopaedic Specialists ( LOS ) is not dependent upon whether you sign this Privacy and Disclosure statement. You have the right to revoke this Privacy and Disclosure Statement at any time by sending a written notice of revocation LOS at 108 Rue Louis XIV, Lafayette, LA 70508, Attn: Privacy Officer. Our Practice Manager and front office staff will be glad to discuss these acknowledgements and authorizations with you. By signing below, I acknowledge that I have received the Notice of Privacy Practices of LOS, which explains its legal duties and privacy practices with respect to my protected health information. I understand that if I have indicated my preferred method of contact is by cell phone, I may receive text message communications regarding my scheduled appointments, appointment reminders and missed appointment notifications. I understand that standard message and data rates may apply. I understand if I choose to opt-out of receiving text message reminders, I am responsible of changing my preferred method of contact with LOS. I hereby agree that LOS may disclose any and all of my protected health information to the following individuals, all of whom are involved in my care for any purpose related to my treatment or the payment of my care. Name: Relationship: Name: Relationship: Name: Relationship: Name: Relationship: Signature of Patient/Patient s Representative: Date: Printed Name of Patient/Patient s Representative: Revised: 7/2017

4 Patient Name: DOB: Anemia Anxiety Asthma Bladder Infections Blood Clots Blood Disorders Cancer Type: Chest Pain COPD Coronary Arterial Bypass Depression Diabetes Fibromyalgia Please list all past surgeries or hospitalizations PATIENT PAST MEDICAL HISTORY Gout Heart Attack Heart Disease Hepatitis High Cholesterol High Blood Pressure Kidney Disease Liver Disease Migraines Neurological Disorder Neuropathy Osteoarthritis Osteoporosis Pacemaker PAST SURGICAL HISTORY Peripheral Vascular Disease Pregnant Psychological Disorder Rheumatoid Arthritis Seizures Shortness of breath History of MRSA (staph infection) Sleep Apnea Stroke Stomach Ulcers Thyroid Disease TB HIV Other: Please list all medications you are currently taking below: MEDICATIONS None Please list all allergies below: None ALLERGIES SOCIAL HISTORY Occupation: When was the last time you worked? L Handed R Handed Restricted or light duty Temporary Permanent disability Retired Unemployed/Seeking Job Are you currently under worker s compensation? Yes No Is there an ongoing lawsuit related to today s visit? Yes No Marital Status: Married Single Divorced Widowed Tobacco: No Yes How many packs per day? How many years? Quit yrs ago Alcohol: No Yes How much do you drink daily? Quit yrs ago Have you ever drank heavily or abused alcohol? No Yes Drugs: Have you ever used any illicit substances? No Yes Type: Have you ever been addicted to or misused prescription drugs? No Yes Check one is someone in your family has/has any of the following Mother Father Sibling(s) Grandparent(s) Diabetes Hemophilia Rheumatoid Arthritis Cancer Stroke Heart Disease Lung Disease Kidney Disease Malignant Hyperthermia Anesthetic Reaction Revised: 7/2017 Spine pg 1

5 Patient Name: Patient DOB: REVIEW OF SYSTEMS Are you currently experiencing any of the following? check here if unknown Yes No Yes No Yes No GENERAL CARDIOVASCULAR GASTROINTESTINAL Loss of appetite Chest pain Nausea or vomiting Recent weight loss Palpitations Blood in stool Fever or chills EYES Heartburn RESPITORY Blurred vision Constipation Shortness of breath Double vision NEUROLOGICAL Chronic Cough Loss of vision Headaches KIDNEY/BLADDER/URINE SKIN Seizures Painful Urination Frequent rashes Dizziness Blood in urine Skin ulcers HEAD/EARS/NOSE/THROAT Kidney problems Lumps Hoarseness HEMATOLOGICAL/LYMPHATIC ENDOCRINE Trouble swallowing Easy bruising Thyroid disease Hearing loss Easy bleeding PSYCHIATRIC Depression Drug/Alcohol addiction Suicidal Thoughts Heat/Cold intolerance HEAD/EARS/NOSE/THROAT Hoarseness Trouble swallowing Hearing loss PATIENT INFORMATION Reason for visit: Does your back pain radiate into your leg? R L Neither How long have you had this pain? Does your neck pain radiate into your arm? R L Netiher Have you had this pain before? Yes No Which is more painful? Back Leg Equal Which is more painful? Neck Arm Equal Was this an injury or accident? Yes No Explain: How long ago? How often does pain occur? Constant (changes in severity but always present) Intermittent (comes and goes, sometimes no pain How would you describe the pain? Dull/Aching Sharp/Stabbing Throbbing Tightness Burning Other My pain symptoms are: Improving Getting Worse Staying the same PAIN LEVEL Numerical Rating Scale (0-10) Highest level in past week? Current pain level? Lowest level in the past week? How severe is your low back pain? How severe is your arm pain? How severe is your neck pain? Highest level in the past week? How severe is your leg pain? ACTIONS EFFECTING PAIN LEVEL What helps the most to improve your pain? What activities are the most bothersome? ASSOCIATED SYMPTOMS Do you have any of the following symptoms? And, if so, please describe: No Yes Remarks Numbness/Tingling Where? Weakness in the arm or leg Describe: Bladder incontinence If yes, is this a change from previous visit? Yes No Bowel Incontinence If yes, is this a change from previous visit? Yes No Sleep Interrupted by pain Activities or hobbies limited due to pain: Do you exercise regularly? Yes No How often? times per week Type: For your current neck or back pain, please mark the boxes for the timeframe that any tests were done: X-Ray < 6 months < 12 months CT < 6 months < 12 months MRI < 6 months < 12 months EMG < 6 months < 12 months Other: Revised: 7/2017 Spine pg 2

6 Patient Name: Patient DOB: PRIOR TREATMENT Please only mark the type of treatment that you have had in the past and how well they worked, otherwise leave blank Physical Therapy Better Worse No Change Chiropractor Better Worse No Change Injections Better Worse No Change PATIENT QUESTIONAIRE Effect of your back/neck pain on your lifestyle I would describe my home setting as supportive of me during this time. Yes No I would describe my work setting as supportive of me during this time. Yes No My pain has affected my interaction with family and friends. Yes No The changes in my lifestyle due to my problem have been difficult for me. Yes No What is your ability to enjoy life? Excellent Very Good Good Fair Poor In general, you would say your health is: Excellent Very Good Good Fair Poor The following questions are about activities that you may do during a typical day Does your health now limit you in these activies? If yes, how much? Bowling or playing golf? Yes, limited a lot Yes, limited a little Not limited at all Climbing several flights of stairs? Yes, limited a lot Yes, limited a little Not limited at all During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? Accomplished less than you would like? Yes No Were limited in the kind of work or other activities: Yes No During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling anxious or depressed)? Accomplished less than you would like: Yes No Did not perform work or other activities as careful as usual: Yes No During the past 4 weeks, how much did pain interfere with your normal work (including work outside the home and housework)? No not at all A little bit Moderately Quite a bit Extremely The following questions are about how you feel and how things have been for you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks: Have you felt calm and peaceful? Not at all A little bit Moderately Quite a bit Did you have a lot of energy? Not at all A little bit Moderately Quite a bit Have you felt downhearted and blue? Not at all A little bit Moderately Quite a bit During the past 3 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? Most of the time Some of the time A little of the time I hereby certify the above information is true and correct to the best of my knowledge. Patient / Representative Name: Patient Signature: Revised: 7/2017 Spine pg 3

7 Patient Name: DOB: Using the appropriate symbol, mark the area(s) of your body where you feel each of the following sensations: Numbness Pins and Needles Burning Aching Stabbing _ ^^^^^^^ XXXXXX R L L R The line below represents the intensity of the pain you are experiencing. Please make and x at the position on the scale in which indicates how much pain you are feeling at this time. No Pain Worst Pain Ever All Back/Neck Back/Neck Equals Arm/Leg All Arm/Leg Revised: 7/2017 Spine pg 4