ATLZ05 Patient Demographics

Atlantic Prosthetics & Orthotics - Patient Demographics Form
Patient Name

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status
Are you a Veteran?
Would you like your bills by
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Driver License Number
Email Address
example@example.com
Parent or Responsible Party (if patient is a child)
Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you currently living in a Skilled Nursing Facility?
If yes, Anticipated discharge date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Information
Weight
Height
Accident date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
State Accident Occurred in
Amputation date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referring Physician
Referring Physician Phone Number
Format: (000) 000-0000.
Primary Physician
Primary Physician Phone Number
Format: (000) 000-0000.
Physician that monitors your Diabetes
Have you had an orthopedic device, shoes, brace, or prosthesis in the last 3 years?
If yes, how long have you had the brace?
What is the primary reason/diagnosis for the device you have been prescribed

Please check any conditions that apply to you

Rows	Condition applies to me
Diabetes
Hypertension
Vascular Disease
Stroke
Heart Problems
Kidney Disease
Osteoporosis
Hepatitis A or B
Hepatitis C
HIV Positive
Rheumatoid Arthritis
Osteoarthritis
Pulmonary Disease
Parkinson Disease
Alzheimer Disease
Pacemaker
Seizure Disorder
Hearing Loss
Vision Problems
MRSA
Currently Pregnant
Gout
Gangrene
Edema - Upper
Edema - Lower

Other Health Conditions
Are you currently employed?
How many hours a day are you on your feet?
Do you have a history of ulcers?
Where are your ulcers?
We will verify your insurance for the device prescribed by your physician and advise you of coverage and any financial responsibility you may have. We cannot guarantee the benefits we quote to you as the insurance companies do not guarantee the benefits they quote to us on your behalf. Please refer to your insurance benefits handbook or call your insurance company for more information.
Digital Signature Authorization:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: