Patient Information(Please print)

Full Legal Name: ______________________________________________________________________ Preferred Name: ______________________________Last First Middle

Date of Birth: ____________________________ SS#: _____________________________ Month/Day/Complete Year

Primary Care Physician: _________________________________________________________________

Preferred Pharmacy Name: _____________________________________________________Phone Number: _____________________________________________

Marital Status: Single Married Divorced Widowed Life Partner Legally SeparatedRace: Caucasian (white) American Indian African American (black) Hispanic

Biracial Asian Other Unknown

Home Address: _________________________________________________________ City: _______________________ State: ___________ Zip: ________________

Mail to Address: ________________________________________________________ City: _______________________ State: ___________ Zip: ________________

County: __________________________ Home Phone: (  )______________________________________ Cell Phone: (  ) _____________________________

Preferred language: __________________________________ E-mail: _________________________________________________________________

Veteran: ___Yes ___No ___Unknown Religion: __________________________________________________________________

Guarantor Information (If guarantor is Self, skip to Emergency Contact)Parent/guardian presenting minor child for treatment will be listed as the guarantor. If 18 or older, patient will be listed as guarantor and does not have to complete this section. The guarantor will be responsible for any balance due.

Name: _______________________________________________________________ Patient relation to Guarantor: __________________________________Last First Middle

Home Phone: (  ) __________________________Date of Birth: ______________________ SS#: _____________________________________ Cell Phone: (  ) ____________________________

Home Address: _______________________________________________City: _________________ State: ________Zip: ___________ Country: _______________Mail to Address(if different): _______________________________________________City: _________________ State: ________Zip: ___________ Country: _______________

Emergency Contact (Pediatric Patients please list someone other than parent(s)/guardian)Primary ContactName: ________________________________________________________________ Home Phone: (  ) ________________________________Patient Relation toEmergency Contact ________________________________________________________________ Cell Phone: (  ) __________________________________SecondaryContact Name: ________________________________________________________________ Home Phone: (  ) ________________________________Patient Relation toEmergency Contact ________________________________________________________________ Cell Phone: (  ) __________________________________

EmploymentPatient Employer: __________________________________________________________________ Work Phone: __________________________ Ext: ____________

Address: ________________________________________________________________ City: _______________________ State: ___________Zip: ________________Employment Status: Full-Time Part-Time Self Employed Active Military Student Full Time

Student Part-Time Retired Date _______ Disabled Not Employed Unknown

(Pediatric Patients Only) Parent/Guardian & Immediate Family InformationMother (If the address, phone numbers and employer information is the same as guarantor, please indicate same.)Full Name: _______________________________________________________________________ Nickname: ___________________________________

Last First MiddleDate of Birth: ___________________________________

SS#: ________________________________________ Month / Day / Complete Year

Home Address: _________________________________________________________ City: _______________________ State: ___________ Zip: ________________(if different from patient)Home Phone: ___________________________________________________ Cell Phone: (  ) _______________________________________________

Employer: ______________________________________________________ Work Phone: (  ) _________________________________ Ext: _______________

Father (If the address, phone numbers and employer information is the same as guarantor, please indicate same.)Full Name: _______________________________________________________________________ Nickname: ___________________________________

Last First MiddleDate of Birth: ___________________________________

SS#: ________________________________________ Month / Day / Complete Year

Home Address: _________________________________________________________ City: _______________________ State: ___________ Zip: ________________(if different from patient)Home Phone: ___________________________________________________ Cell Phone: (  ) _______________________________________________

Employer: ______________________________________________________ Work Phone: (  ) _________________________________ Ext: _______________

Sex: Male FemaleEthnicity: Hispanic/Latino

Non-Hispanic/Non-Latino Refuse/Decline

PATIENT DEMOGRAPHICS 118947 (12/19) PAGE 1 OF 2

Patient Name ___________________________________________________________ DOB _________________________________________________

(Pediatric Patients Only) Brothers, Sisters & Other Family Members

Full Name M or F Date of Birth Relationship Lives with child

Yes No

Yes No

Yes No

Yes No

Check here if no insurance. And, skip to Authorization (below).

Accident Information

Is visit the result of an accident? (Examples: auto accident, workers compensation, etc.) Yes No

Type of Accident: __________________________________ Date of Accident: _________________________ County of Accident: __________________________

Primary Insurance InformationSubscriber: This is the person who carries the insurance. If Subscriber is the Patient, skip to Insurance Co Name field.

Subscriber’s Name on card: ____________________________________________________________ Date of Birth: ______________________________Month / Day / Complete Year

Patient Relationship to Subscriber: __________________________________ Sex:  Male   Female

If address and phone number is same as patient, please indicate same.

Address: _________________________________________________________________ SS#: ____________________________________

City, State, Zip: _________________________________________________________________ Home Phone: ________________________________________

Employer: ____________________________________________________________ Work Phone: _____________________________ Ext. ___________

Insurance Co. Name: ___________________________________________________________ Phone: ____________________________________

Policy/Cert #: ____________________________________Group No: ______________________ Effective Date: ___________________________

Subscriber Status: Full-Time Part-Time Self Employed Active Military Student Full Time Student Part-Time Retired Date ____________ Disabled Not Employed  

Secondary Insurance InformationSUBSCRIBER: This is the person who carries the insurance. If Subscriber is the Patient, skip to Insurance Co Name field.

Subscriber’s Name on card: _________________________________________________________________ Date of Birth: _________________________________Month / Day / Complete Year

Patient Relationship to Subscriber: __________________________________ Sex:  Male   Female

If address and phone number is same as patient, please indicate same.

Address: _________________________________________________________________ SS#: ____________________________________

City, State, Zip: _________________________________________________________________ Home Phone: ________________________________________

Employer: ____________________________________________________________ Work Phone: _____________________________ Ext. ___________

Insurance Co. Name: ___________________________________________________________ Phone: ____________________________________

Policy/Cert #: ____________________________________Group No: ______________________ Effective Date: ___________________________

Subscriber Status: Full-Time Part-Time Self Employed Active Military Student Full Time Student Part-Time Retired Date ____________ Disabled Not Employed 

Authorization

I authorize medical evaluation & treatment, and release of information for insurance/medical purposes concerning my illness and treatment. I hereby authorize payment from my insurance company to the Prisma Health for services rendered. I will be responsible for any amount not covered by my insurance.

Signature of Patient/Guardian/Guarantor: _______________________________________________________________ Date: __________________________

PATIENT DEMOGRAPHICS 118947 (12/19) PAGE 2 OF 2

HEALTH HISTORY QUESTIONNAIRE – NEW PATIENT Questions contained in this questionnaire are strictly confidential & will become part of your medical record. Please answer to the best of your ability. PLEASE COMPLETE FRONT & BACK OF PAGE

FOR OFFICE STAFF USE ONLY

BP: PULSE: TEMP: WEIGHT: HEIGHT:

Medical History (check all that apply) □ Cancer □ GERD □ Hypertension □ Stroke

□ Clotting Disorder □ Heart Condition (specify): __________ □ Kidney Disease □ Blood Clot______________

□ Diabetes Mellitus □ Hepatitis (specify A,B,C): ___________ □ Osteoporosis/Osteopenia □ OTHER________________

□ Emphysema □ HIV/AIDS Hypertension □ Parkinson’s Disease □ OTHER________________

Current Medications: Name Strength How Taking

Allergies: Name Reaction

Preferred Pharmacy: __________________________________ Phone: ____________________________

DATE:_________________

Surgical History Type Date Surgeon

(OVER FOR PG 2)

Name: _________________________________ Preferred Name: ___________________Date of Birth: ___________

Reason for today’s visit: ___________________________________________ Onset/Date of Injury: _________________

Pain Scale: (circle one) □ NO PAIN

0 1 2 3 4 5 6 7 8 9 10

Pain Description Pain Frequency Pain Progression □ Aching □ Numb □ Constant/Continuous □ Not Changed □ Burning □ Sharp □ Rarely Gradually: □ Worsening □ Improving □ Cramping □ Shooting □ Intermittent Rapidly: □ Worsening □ Improving □ Discomfort □ Other:_______________ □ Other:________________ □ Resolved □ Dull □ Other:_______________ □ Other:__________________________

Level of Activity/Exercise: On average, how many days a week of moderate to strenuous exercise (e.g. a brisk walk)? ____________________ On average, how many minutes do you exercise per day? ____________________ Total minutes of exercise per week: ____________________

Family History Relationship Medical Condition(s)

Mother:

Father:

Brother:

Sister:

Other (specify):

Social History

□ No History of Tobacco Use □ I Do Not Drink Alcohol □ No History of Drug Use □ Tobacco Use

Type: ___________________ Frequency: ___________________ Duration: ___________________ Quit Date:___________________

□ Alcohol Use Type: ___________________ _____ /Day _____/Week

□ Drug Use Type: ___________________ Frequency: ___________________ Duration: ___________________ Quit Date: ___________________

Review of Systems

□ Adopted

□ Family History Unknown

Orthopaedic Surgery and Sports Medicine Fellowship Program

Information and Disclosure Statement During your visit today you may be examined by a physician who is participating in

the Steadman Hawkins Clinic of the Carolinas Fellowship Program. Fellowship

programs are accredited, one year fellowships in which fully trained orthopaedic

surgeons and primary care physicians are chosen from the top medical schools and

residency programs across the country to do an additional year of study to focus on

shoulder and knee reconstruction and sports medicine. Annually, a group of six

physicians is chosen from over 100 applicants to participate in the Orthopaedic

Surgery Fellowship Program and two physicians for the Primary Care Sports

Medicine Fellowship.

If a Fellow is caring for you, he will introduce himself and state that he will be working

closely with the consulting doctor in your ongoing care. A plan of treatment is suggested by the Fellow and finalized by the supervising surgeon or physician. In the

operating room, before your surgery, the Fellow will meet with you, along with the

consulting surgeon. T h e Fe l l o w m a y p a r t i c ip a t e i n t h e s u rg i c a l p r o c ed u r e i n t h e o p er a t i ng roo m . After surgery, the Fellow, along with the consulting

surgeon, will see you on rounds.

A Fellow's role in surgery is under the direct supervision of one of our surgeons who is

present during all cases. All patient interaction is under close supervision of the Steadman Hawkins Clinic physicians. Steadman Hawkins Clinic is also part of the

Greenville Health System Orthopaedic Residency Program. Residents are medical doctors in training to become orthopaedic surgeons. They may be involved in your care

as well and will perform his/her role under supervision of the Steadman Hawkins Clinic

physician.

Having trained over 150 surgeons world-wide, we are proud of our fellowship program.

It is one of the best in the country and the only ACGME Accredited Orthopaedic Sports

Medicine Fellowship in South Carolina. It is important for our patients and the

community to know that our fellowship and residency programs, along with the Steadman

Hawkins Clinic physicians, provide a large talented team to deliver to you the best

possible medical care.

Please feel free to ask the Fellow or the consulting physician any questions you might

have regarding the Steadman Hawkins Clinic of the Carolinas Fellowship Programs.

Patient Signature Date of Birth Date

_______________________________ Patient’s Printed Name

Orthopaedic Surgery and Sports Medicine Fellowship Program 121779 (6/19) PAGE 1 OF 1

107949 (7/19)Authorization for Disclosure of Medical Information PAGE 1 OF 1

Disclosure Med InfoPrisma Health-Upstate

Authorization for Disclosure of Medical Information

Patient Full Name (PRINT) ________________________ DOB ______________ MRN _______________

Authorization for Disclosure of Medical Information: The privacy of your medical information is important. We will discuss your medical condition with person(s) you designate.

DO YOU WANT TO DESIGNATE A FAMILY MEMBER OR OTHER INDIVIDUAL WITH WHOM THE PROVIDER MAY DISCUSS YOUR MEDICAL CONDITION? IF YES, WHOM? (Check and complete one)

� YES - The provider may discuss my medical condition with the following family member or other individual: ____________________________________________________________________________________

____________________________________________________________________________________

� NO The provider may not discuss my medical condition with any family member or other individual.

You may revoke/cancel or modify/change the above designation, but the revocation or modification must be in writing.

NOTE: This designation does not give the above named individuals the right to make health care decisions for you. If at any time you are unable to consent to care or treatment, we will follow the procedure set forth in the South Carolina Adult Health Care Consent Act.

Communication: Please provide phone number(s) where we can reach you (by providing a number you also authorize Prisma Health to leave you voicemails at the number(s) listed):

� Home: ___________________ � Cell: _____________________ � Work: ____________________

Note: An automated appointment reminder system may call the number listed in our data base.

Signature: I hereby authorize the disclosure of my medical information as described above.

Patient/Patient’s Representative Signature: ___________________________ Date: _____Time:_____

PRINT Name (if Patient’s Representative): _______________________________________________

Relationship to Patient (if Patient’s Representative):___________________________________________

Prisma Health Representative:

Date: ______Time:____

107950 (7/19)Authorization for Disclosure of Medical Information - Spanish PAGE 1 OF 1

Disclosure Med InfoPrisma Health-Upstate

Autorización Para Divulgación De Información Médica

Nombre completo del paciente (EN LETRA DE IMPRENTA) _____________________________________

Fecha de nacimiento __________________ NRM ________________________

Autorización para la divulgación de información médica: La privacidad de su información médica es importante. Discutiremos su estado de salud con la(s) persona(s) que usted designe.

¿DESEA DESIGNAR A UN MIEMBRO DE LA FAMILIA U OTRO INDIVIDUO CON QUIEN EL PROVEEDOR PUEDA DISCUTIR SU ESTADO DE SALUD? Si ES ASÍ, ¿A QUIÉN? (Marque y complete uno)

� SÍ - El proveedor puede discutir mi estado de salud con el siguiente miembro de la familia u otro individuo: ____________________________________________________________________________________

____________________________________________________________________________________

� NO El proveedor no puede discutir mi estado de salud con ningún miembro de la familia u otro individuo.

Usted puede revocar/cancelar o modificar/cambiar la designación anterior, pero la revocación o modificación debe hacerse por escrito.

NOTA: Esta designación no les otorga a los individuos mencionados anteriormente el derecho de tomar decisiones de cuidado de salud por usted. Si en algún momento usted no puede dar su consentimiento para el cuidado o el tratamiento, nosotros seguiremos el procedimiento establecido en la Ley de Consentimiento de Cuidado de Salud para Adultos de Carolina del Sur.

Comunicación: Por favor, proporcione el número(s) de teléfono donde podamos comunicarnos con usted (al proporcionar un número, también autoriza a Prisma Health a dejarle mensajes de voz en el número(s) que proporcionó):

� Casa: ___________________ � Celular: _____________________ � Trabajo: ____________________ Nota: Un sistema automatizado de recordatorio de citas podría llamar al número que figura en nuestra base de datos.

Firma: Por la presente autorizo la divulgación de mi información médica como se describe anteriormente.

Firma del paciente/Representante del paciente: ________________________ Fecha: _____ Hora: _____

Nombre EN LETRA DE IMPRENTA (si es representante del paciente): ______________________________

Relación con el paciente (si es el representante del paciente): ___________________________________

Prisma Health Representative: Date: ______Time:____

This 8.5 x 11 prototype requires final approval.

Once fully blessed, the text and layout will be converted to uneditable art. This

will guard against inadvertent changes relating to characters, flow, and font

specs. From this art, all remaining posters, flyers, etc, will be created.

If changes are necessary in the future, a new art file will need to prepped (ie,

changes will not be possible on individual projects).

Discrimination is against the law

Prisma Health does not discriminate on the basis of race; color; national origin; religion; age; sex; physical, mental or other disability; medical condition; sexual orientation; gender identity; gender expression; pregnancy; ancestry; marital status; citizenship; or veteran status.

Prisma Health provides appropriate aids and services, including qualified interpreters and written information in various formats, for people with disabilities. It provides language assistance services, including translated documents and oral interpretation, to people whose primary language is not English. All services are timely and offered for free. Those needing these services in the Upstate should call 864-455-7000.

Prisma Health has designated its Diversity Director to ensure compliance with these services. Any person who believes someone has been discriminated against may submit to the Diversity Director, within 60 days of becoming aware of the alleged discrimination, a written complaint with the name and address of the person filing the grievance, as well as the problem or action alleged to be discriminatory.

Complaints may be filed at Diversity@PrismaHealth.org or 701 Grove Road, Greenville, SC 29605, attn. Diversity Director. Individuals may file a complaint in court or with the U.S. Department of Health and Human Services, Office of Civil Rights, by mail at 200 Independence Ave. SW, Room 509F, HHH Building, Washington, DC 20201, by phone at 1-800-368-1019 or online at https://ocrportal.hhs.gov/ocr/office/file/index.html.

Language assistance information

Si usted habla español, tenemos a su disposición servicios gratuitos de asistencia lingüística. Llame al 864-455-7000. (Spanish)

如果您说中文，傳譯服務可免费提供服务。您可以拨打。864-455-7000 (Chinese)

Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 864-455-7000. (Vietnamese)

한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 864-455-7000 번으로 전화해 주십시오. (Korean)

Si vous ne maitrisez pas bien la langue anglaise, des services gratuits d’assistance linguistique sont disponibles au numero suivant 864-455-7000. (French)

Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 864-455-7000. (Tagalog)

Если Вы говорите на русском языке, то Вам доступны бесплатные услуги переводчика. Звоните 864-455-7000. (Russian)

Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 864-455-7000. (German)

જો તમે ગુજરાતી જાણતા હોય તો, ભાષા સહાયક સેવાઓ, િવના મુલયે , તમારા માટ ેઉપલબ્ધ છે. ફોન કરો (૮૬૪) ૪૫૫-૭૦૦૦. (Gujarati)

(Arabic) .864-455-7000 إذا كنت من الناطقين باللغة العربية، تتاح خدمات المساعدة اللغوية لك. اتصل على الرقم

Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 864-455-7000. (Portuguese)

注意事項：日本語を話す場合、言語支援サービスは無料でご利用できます。864-455-7000 までお電話ください。(Japanese)

Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 864-455-7000. (Ukrainian)

अगर आप िहंदी बोलते हैं, तो आप के िलए िन: शलुक भाषा सहायता सेवाएँ उपलब्ध हैं। 864-455-7000 पर कॉल करें। (Hindi)

ប�ើបោកអ្នកនិយាយភាសាខ្មែរ បោកអ្នកអាចប្�ើ្រាស់បសវាជំនួយភាសារានបោយឥតគិតថ្លៃ។ បៅទូរសព្ទបៅបេ្ 864-455-7000។(Cambodian)

8.5” x 11” brochure: inside page