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Dallashipandkneesurgery.com

Kurt W. Rathjen, M. D.
Patient Registration Form

PATIENT INFORMATION
Patient’s Name:________________________________________________________ Sex: M F Marital Status:_________________
SS#____________________________________ DOB__________________________________ Age____________________________ Home Address:______________________________________________________________________________________________________ Home Phone: (____)_____________________ Work Phone: (____)______________________ Fax:(____)__________________________ Cell Phone: (____)_______________________ E-Mail: _________________________________________________________ Employed: Full Part-time Name of Employer: _________________________________________________________________________
Student: Full Part-time Name of School: ____________________________________________________________________________
PARENTAL INFORMATION FOR MINORS (for patients under the age of 18)
Mother’s Name:_________________________________________ Father’s Name:______________________________________________ Mother’s Date of Birth: _______________ SS#_______________ Father’s Date of Birth: _________________ SS#_________________ FAMILY PHYSICIAN
Name: _____________________________________________ Phone No.: _____________________________________________ Address: _________________________________________________________________________________________________________ WHO SENT YOU TO OUR OFFICE
Name: _____________________________________________ Phone No.: _____________________________________________ Address: _________________________________________________________________________________________________________ EMERGENCY CONTACT- Name of relative or friend not living at your address to contact in case of emergency:
Name: _______________________________________________ Phone No.: ______________________________________________ Address: ___________________________________________________________________________________________________________ Kurt W. Rathjen, M.D.
Health History Questionnaire
Please print, answer all questions and sign where indicated
Patient’s Name:____________________________________________ Date of injury/onset of problem:____________________________ Indicated body part(s) affected: _________________________________________________________________________________________ Please describe your injury or problem: __________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Was this an automobile accident? Yes No
Were you injured on the job? Yes No
MEDICATION HISTORY
ALLERGIES: PLEASE CIRCLE ALL THAT APPLY
ARE YOU ALLERGIC TO ANY METAL OR JEWELRY? _______________________________________________________ Please list all medications you are currently taking, REMEMBER to include vitamins, herbs, minerals, & antibiotics
Current Medications
Frequency
Current Medications
Frequency
PAST MEDICAL HISTORY - Please circle any current or past illnesses
Cancer (specify) __________________________ Other _______________________________________ PAST SURGICAL HISTORY - Please circle all that apply
Neck surgery Fracture Repair (specify site) ______________________________________________ Total Hip or Partial Hip Replacement: R L Total Knee Replacement: R L
Other: ____________________________________________________________________________________________________________ FAMILY HISTORY – Please circle all that apply or fill in blanks
Father: Age if living _________ Deceased at age _________ Mother: Age if living _________ Deceased at age _________ Is there a family history of: (Please circle Yes or No)
Diabetes Yes No
High Blood Pressure Yes No
Sudden Unexplained Death Yes No
Asthma Yes No
Arthritis Yes No
SOCIAL HISTORY - Please circle or fill in blanks
Occupation: _________________________________________ Highest level of Education completed: _____________________ Alcohol: Number of drinks per week ___________ Smoking: Number of Packs per day _____________ for _________ years Quit smoking on or about ________________ Smoked # packs/day_________ for _________ years Illicit Drug Use: ___________________________________________ REVIEW OF SYSTEMS: (Please mark all that have occurred in the past year)
CONSTITUTIONAL
EYE & VISION
EARS & HEARING
NOSE & THROAT
CARDIOVASCULAR
RESPIRATORY
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
NEUROLOGIC
PSYCHIATRIC
SKIN & BREAST
ENDOCRINE
HEMATOLOGIC/
ALLERGIC/
LYMPHATIC
IMMUNOLOGIC
To my knowledge the above information is correct. I give my consent for treatment for this illness or injury described herein and I understand that I am financially responsible to
Kurt W. Rathjen, M.D. for all charges not covered by any and all insurances. Payment is expected at the time services are rendered. I understand that both parents of a minor
patient may be asked to sign a statement of financial responsibility. I authorize payment directly to Kurt W. Rathjen, M.D. of any insurance policy benefits payable to me,
and I herby assign all such policy benefits to Kurt W. Rathjen, M.D.

________________________________________________________________________________________________________________________________________________
PATIENT’S SIGNATURE

SIGNATURE OF ADDITIONAL RESPONSIBLE PARTY

Source: http://www.dallashipandkneesurgery.com/pdf%20files/pt%20forms/pt_registration.pdf

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The new england journal of medicineParecoxib and Valdecoxib after Cardiac SurgeryNancy A. Nussmeier, M.D., Andrew A. Whelton, M.D., Mark T. Brown, M.D., Richard M. Langford, F.R.C.A., Andreas Hoeft, M.D., Joel L. Parlow, M.D., Steven W. Boyce, M.D., and Kenneth M. Verburg, Ph.D. b a c k g r o u n d Valdecoxib and its intravenous prodrug parecoxib are used to treat postoperative pain Fr

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