Preferred OrthoMaryland physician (select one): Choose a Physician (Optional) Jerome Reichmister, M.D. Larry Becker, M.D. William Smulyan, M.D. Robert Keehn, M.D. Mark Rosenthal, M.D. Robert Riederman, M.D. Steven Friedman, M.D. Ian Weiner, M.D. Barry Waldman, M.D. Jon Koman, M.D. Michael Scheerer, M.D. Jason Phipps Brokaw, M.D. David P. Buchalter , M.D. Peter R. Jay, M.D. Lisa J. Grant, M.D. Benjamin N. Carr, III, M.D. Mark A. Deitch, M.D.

Referred by: self         family/friend         physician         emergency room

Primary care physician:          

New patient first name:

M.I. (optional): Patient last name:

Address:
Street

City State Maryland Delaware District of Columbia New Jersey New York Pennsylvania Virginia West Virginia Zip Code

Day phone : home work cell
- - ext.

E-mail address:

Briefly describe the reason for your visit:

Preferred weekday for appointment:
Monday Tuesday Wednesday Thursday Friday

Preferred time: a.m. p.m.

NOTE: We will make every effort to accommodate the day and time you prefer for an appointment. However, when this is not possible, we will work with you to schedule an alternate appointment that works best for you. Thank you in advance for your patience in this matter.

Insurance (Choose One): Aetna Alliance PPO BCE Emergis (Thru Multi-plan) Beech Street CareFirst Blue Cross and Blue Shield (PPN and Indemnity) CareFirst Blue Cross and Blue Shield (Federal) CareFirst Blue Choice Choice Care Network Cigna Healthplan Commerical Carriers Coventry Health Plan—HMO and PPO Products (Not Medicaid) E.H.P. (Johns Hopkins HealthPlan) Fidelity Benefit Administrators/PMG Network Great West Insurance Humana/Choice Care Network Lifebridge Health Insurance (Not Scheerer and Little) MAMSI MDIPA Medicare Multi-Plan NCAS National Capital PPO Optimum Choice (HMO) Palmetto/Medicare Railroad P.H.C.S. P.H.N. (Preferred Health Network) Tri-Care Standard and Tri-Care for Life United Health Care (NOT Chesapeake Family First) Other

Insurance Member Number:

Group Number:

Social Security Number: - -

Policy holder's first name:

Policy holder's last name:

Policy holder's date of birth : - -

Employer:

Employer's Address:
Street

City State Maryland Delaware District of Columbia New Jersey New York Pennsylvania Virginia West Virginia Zip Code

Medical History

Past and present medical problems (check any and all that apply):

If you chose cancer, please list type:

If you chose heart attack please list what year it occured:

If you chose "other," please list medical problem(s) here:

List any prior surgery (include year):

List all medications you are currently taking (include all over-the-counter drugs and alternative/herbal preparations, what condition they treat, the strength and dosage):

List all allergies to medicines (including herbal) and other items
(include talc, adhesive tape, foods, etc.):

Height: Feet Inches

Weight: lbs.

Handedness: Right Left

Family History

List any medical illnesses for each member. Please make sure you distinguish between whether or not you have NO SISTERS/BROTHERS OR CHILDREN or they have NO MEDICAL PROBLEMS.

Father:

Mother:

Sisters:

Brothers:

Grandparents:

Children:

List any other diseases, which occur in your family and the family member’s relationship to you:

If you chose cancer, please list type:

If you chose "other," please list medical problem(s) here:

Social history:
Please indicate who you live with and their relationship to you:

Do you use tobacco now? yes     no     Type and Amount:
Did you use tobacco in the past? yes     no     Type and Amount:
Do you drink alcohol? yes     no     If yes, weekly amount:
Do you use illicit drugs? yes     no     If yes, weekly amount:

Symptoms you currently have or have had in the past year (check all that apply):

Other (please list):

If you would prefer to talk to an appointment scheduler in person, call 410-377-8900. Or, please call if you have any other questions or concerns.

To our new patients: We look foward to meeting your orthopaedic needs.

Please do not use this form for any type of orthopaedic emergency matter. In the case of an emergency,
all us at 410-377-8900, or if necessary, call emergency services, 9-1-1, after regular business hours.

You or your parent or guardian may be required to sign a copy of this form upon your visit.