Email your questions about
the recent webcast to info@orthomercy.com.

The Orthopaedic Institute
At Mercy Hospital

Outpatient Center
3659 S. Miami Ave. | Suite 4008
Miami, FL 33133 (USA)

Tel. (305) 285-5085
Fax. (305) 285-5084
info@orthomercy.com


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Personal information
Name
Age
Telephone
Referred by
Are you a new patient? Yes No
Insurance Medicaid Medicare HMO PPO
 
Other If Other
  International
Self Pay
Is this a litigation case? Yes No
Is your injury work related? Yes No
   

Current Problem(s)
  Neck Left Right Both
  Shoulder Left Right Both
  Elbow Left Right Both
  Wrist Left Right Both
  Hand Left Right Both
  Back Left Right Both
  Hip Left Right Both
  Knee Left Right Both
  Ankle Left Right Both
  Foot Left Right Both
  Fracture
  Sprain/Strain
  Dislocation/
Separation
  Other
 

Experiences
How did it happen
Chief Complaint(s) Locking Loss Of Motion Numbness
Pain Swelling
Average Pain
 

History
Have you had any studies done?

Yes No
If Yes, which study has been done?
(you will need to provide them when requested)
MRI CT Bone Scan Xray
   
Have you ever had any numbness
or tingling down the arm and/or leg?		 Yes No
  If Yes - How far down?
   
Have you ever had an Xray? Yes No
  If Yes - What did it show?
   
Has any physician ever diagnosed
you with Arthritis?		 Yes No
   
Previous Surgeries
Medications taken for the current pain Aspirin Antibiotics Coumadin
Motrin Steroids Other
   
Have you been told you need surgery? Yes No