Dr. Lilia Gorodinsky D.O.

NYC Osteopathic, PLLC

405 Lexington Avenue, 26th Floor

T: 212-537-0614 | F: 917-423-0452

nyosteo1@gmail.com | nyosteo.com

Welcome!

NEW PATIENT REGISTRATION FORM:	PLEASE PRINT or TYPE

Fax completed form: 917-423-0452 or bring it with you to your appointment.

PERSONAL INFORMATION

Today’s Date:

Name: Birth Date: Sex:

Address:

Email: Referred by:

Home phone: Work: Cell:

Closest relative:

Address: Phone:

Spouse/significant other:

Who lives at home?

Employer: Occupation:

Medications/Supplements/Herbs/Home Remedy:

Allergies (Y,N): (please list)

Any medications?

DIET: (please describe)

Breakfast:

Lunch:

Dinner:

Exercise: (please describe)

Education:

INSURANCE INFORMATION:

Please fill out the following information for the holder of the insurance policy or legal guardian.

Insurance Co. Group # Policy #

Insured name: Birth Date: Sex:

Please list Surgeries, Serious Injuries, Fractures or illnesses, or hospitalizations:

Event	Date	Outcome

REASON FOR VISIT:

Explain:

Was there an initiating event?

What was different within 6 months before the onset of the problem:

LOCATION:

Where does it hurt?

(Using the symbols below, mark the areas of your body where you feel the described sensation. Include all affected areas.)

WORSE PAIN= WWW ACHING= AAA SHOOTING= SSS PAIN=PPP

NUMBNESS= NNN BURNING= BBB TINGLING= TTT STABBING= ZZZ

Right Left Right Right Left Left

INTENSITY: How bad is the pain? (Circle the number 0=no pain, 10 = worst pain possible)

NOW: 1 2 3 4 5 6 7 8 9 10

At ITS WORST: 1 2 3 4 5 6 7 8 9 10

AT ITS BEST: 1 2 3 4 5 6 7 8 9 10

ONSET: When did it start? (Most recent episode) ________________________________

DURATION: (since initial event) _____________________________________________

QUALITY: (circle all that apply)

1. Sharp dull burning deep ache pressure pins and needles other_______________

TIMING: constant?____ or intermittent?____

Worse: morning?____ afternoon? ___evening? ____ night awakening?____ Same all day?____

WHAT MAKES IT WORSE? (circle all that apply)

Sitting Standing Walking Lying down Sustaining one position

Changing position (e.g. sit to stand, turn over in bed) other_______________

WHAT MAKES IT BETTER? (circle all that apply)

Sitting Standing Walking Lying down Rest Stretching Exercise Heat Ice other_______________

Have you had any of the following tests for this or a similar problem? Fill in dates.

(approx.) X-Ray? MRI? CT scan?

Bone Scan? Myelogram? Other?

Treatments for this problem?

Manipulation (osteopathic/chiropractic): When? ________________ Result? ___________________

Medications: (types)_____________________________________ Result? ___________________

Injections: (types) __________________________When? ____ Result? _______________________

Physical Therapy? When? _________________For how long? _______ Result? ________________

Surgery? (types) _____________________ When? ____________ Result? ____________________

DOES PAIN AFFECT YOUR (check all that apply):

Daily Routine? How?

Mood? How?

Recreation? How?

Work? How?

Sleep? How?

Sex life? How?

MEDICAL HISTORY

Check every condition you have had ever had. Circle conditions currently present. Write age of onset.

EYES

Failing vision

Double or blurred vision

Squinting/“crossed” eyes

Asymmetric gaze

Eye pain

Eye infections

Lose placement reading

Poor reading comprehension

Eyestrain or fatigue from reading

Headache from reading

Glasses or contacts

Monovision/progressive lens

ENT

Decreased hearing

Loud voice

Snoring/mouth breathing

Ringing/buzzing in the ears

Ear infections

Allergies/hay fever/runny nose

Sinus problems,

Nosebleeds

Frequent sore throats

Prolonged hoarseness

Speech problems

CARDIOPULMONARY

Asthma

Emphysema

 Chronic cough

Bronchitis

Pneumonia

Tuberculosis

Shortness of breath on exertion

Shortness of breath on lying flat

Chest pains

Heart murmurs

Palpitations

Swollen ankles

Fainting spells

Weight leg pain when walking

Varicose veins/phlebitis

GI

Eating disorder

Recent loss of appetite

Difficulty swallowing

Heartburn

Persistent nausea/vomiting

Ulcers

Chronic abdominal pain

Recent change in bowel habits

Diarrhea

Constipation

Black or tarry stools

Red blood in stools

Hemorrhoids

Diverticulosis

Gallbladder trouble

Jaundice/hepatitis

Hernia

ENDO

Chronic fatigue

Recent weight loss

Excessive weight gain

Thyroid disease

Cancer

Diabetes

NEURO

Convulsions/seizures

Stroke

Tremors

Muscle weakness

Numbness/tingling sensation

Frequent headaches

Clumsiness

MS

Joint pain

Scoliosis/kyphosis

Arthritis

Gout

Cold or numb feet

Involved in contact sports

DERM

Rashes

Psoriasis

Eczema

Hives

Unusual moles

PSYCH/EMOTIONAL

Difficulty sleeping

Nightmares

Nervousness/anxiety

 Stress

Depression

Memory loss

Moodiness

Phobias

Nail biting/thumb sucking

Bad temper/breath-holding

Jealously

ILLNESSES

Mumps

Measles

German measles

Chicken pox

Polio

Scarlet fever

Rheumatic fever

TB

Meningitis

HABITS

Alcoholism

Alcohol _______________

Cigarettes__________/day

Coffee/tea______ cups/day

Chocolate

Sugar

Other

HEME

Anemia

Malaria

Bruise easily/bleeding

Mononucleosis

Unexplained lumps

Fever/chills/excessive sweating

GU

Bedwetting

 Bladder infections

Kidney infection

Pain on urination

Poor control of urination

 Decreased force of urination

Blood in urine

Kidney stones

Discharge from penis or vagina

Sexually transmitted disease

FEMALE ONLY:

Number of pregnancies_________

Number of live births___________

Number of miscarriages_________

Method of birth control__________

Age of onset of menses ________

Flow:  Light Moderate Heavy

Length of flow_________________

Length of cycle ________________

Period not regular

Pain/bleeding with intercourse

 PMS (medium to severe)

STRESS

Check any of the following that occurred in your family the past year:

Married Births Serious illness

DivorcedDeathsSeparation Job loss Move Other_____

DENTAL

Orthodontic treatment: age______

Dental extractions

Crowns

Root canal work

Fillings

Bridgework

Retainer/nightguard

Gum problems

TMJ

OTHER MEDICAL Conditions not listed above:

Major life trauma and or stressor (physical or emotional):

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OTHER MEDICAL TREATMENT: List all physicians from whom you are currently receiving treatment along with the condition(s).

Physician Name	Illness(es)	Treatment program

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Current Medications and Supplements:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Family History:

Mother_______________________________________________________________________

Father________________________________________________________________________

Maternal Grandmother__________________________________________________________

Maternal Grandfather___________________________________________________________

Paternal Grandmother___________________________________________________________

Paternal Grandfather____________________________________________________________

NYC Osteopathic, PLLC	Effective: April 1, 2003

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Introduction

This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA).

At NYC Osteopathic, we are committed to treating and using protected health information about you responsibly. This Notice of Health Information Privacy Practices describes the personal health information we collect, and how and when we use or disclose that information. This notice also describes your rights as they relate to your Protected Health Information. This notice is effective November 1, 2010, and applies to all protected health information as defined by federal regulations.

Acknowledgment of Receipt of this Notice

You will be asked to provide a signed acknowledgment of receipt of this notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care service will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide you treatment, and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.

Understanding Your Health Record/Information

Each time you visit NYC Osteopathic, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

•	Basis for planning your care and treatment,

•	Means of communication among the many health professionals who contribute to your care,

•	Legal document describing the care you received,

•	Means by which you or a third-party payer can verify that services billed were actually provided,

•	A tool in educating health professionals,

•	A source of data for medical research,

•	A source of information for public health officials charged with improving the health of this state and the nation,

•	A source of data for our planning and marketing,

•	A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve,

Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

Your Health Information Rights

Although your health record is the physical property of NYC Osteopathic, the information belongs to you. You have the right to:

•	Obtain a paper copy of this Notice of Privacy Practices upon request,

•	Inspect and obtain a copy your health record as provided for in 45 CFR 164.524,

•	Request to Amend your health record as provided in 45 CFR 164.528,

•	Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528,

•	Request communications of your health information by alternative means or at alternative locations,

•	Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and,

•	Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Our Responsibilities

NYC Osteopathic is required to:

1.	Maintain the privacy of your health information,

2.	Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you,

3.	Abide by the terms of this notice,

4.	Notify you if we are unable to agree to a requested restriction,

5.	Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative location, and

6.	Obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law.

NYC Osteopathic reserves the right to change our Privacy Information practices and to make the new provisions effective for all protected health information we maintain. Revised notices will be available to you at this office during business hours, or by mail if requested. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

Examples of How NYC Osteopathic May Use or Disclose Your Health Information

For treatment, payment, health care operations, appointments, to appropriate business associates, notification, or communication with family members, research, funeral director, organ procurement organizations, marketing, Food and Drug Administration (FDA), Workers Compensation, Public Health Department, in cases as required by law, public health and safety, and for certain government functions.

For More Information or to Report a Problem, or If you have questions and would like additional information, you may contact our practice.

NYC Osteopathic,PLLC

405 Lexington 26th floor, suite 2634

New York NY 10174

Phone: (212) 537-0614

Fax: (917) 423-0452

If you believe your privacy rights have been violated, you can file a complaint with the practice, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the practice or the Office for Civil Rights. The address for the OCR is listed below:

Office for Civil Rights - U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Room 509F, HHH Building

Washington, D.C. 20201

866-OCR-PRIV (866-627-7748) or 886-788-4989 TTY

Effective Date: April 1, 2003

Acknowledgment of Receipt of this Notice

Note this is to document that I have received a copy of the notice of crepitus he practices for NYC Osteopathic, PLLC. I have read this copy and agree to the terms

Name of Patient (PRINT)_______________________________________________________________________________

____________________________________________________________________________________________________	______________________

Signature of Patient or Authorized Representative	Date