New Patient Form for Dr. Lewiecki

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Patient's Name

First

Last

Age

Who referred you to us?

Who is your primary care physician?

What is the reason for this consultation?

Gender

Female
Male

Are you retired?

Should we send a copy of the consulation report to anyone else?

Have you had a bone density test?

Are you interested in participating in an osteoporosis research study if you qualify?

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Have you had X-rays, CT scan, or MRI of your spine?

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Have you ever had X-ray therapy for any reason?

Osteoporosis Risk Factor Assessment

If you answered yes to any of these questions, please give details below:

Please provide details requested below if you have ever taken any of the listed medications.

For each medication checked above, please list the dose (# pills or mg.), date started, date stopped, and the reason the medication was stopped below.

Have you ever had any operations?

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Please make additional comments here:

Please check to indicate any RECENT symptoms.

Appealing Insurance Denials

I authorize NMCROC to enact appeals on my behalf to my primary and secondary (if applicable) insurance carriers as it relates to denials for the following: in-office treatment, authorized injectable medications, claim denials, prescription medication and durable medical equipment. I understand that by allowing NMCROC to appeal denials on my behalf, I am not guaranteed a positive outcome.

Signature

Today's Date

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Contact

300 Oak Street NE, Albuquerque, NM 87106

Medical Practice

Phone:505-855-5525

Fax: 505-884-4006

Billing:505-855-5525

Emergency: 505-857-3844

Research Center

Phone: 505-855-5505

Fax: 505-855-5506

Emergency: 505-857-3844

Study Recruiter: 505-923-3232

	Yes	No
Have you lost more than 2 inches in height?	YesHave you lost more than 2 inches in height? Yes	NoHave you lost more than 2 inches in height? No
Have you ever broken a bone? (list your age, date, and circumstances for every fracture below)	YesHave you ever broken a bone? (list your age, date, and circumstances for every fracture below) Yes	NoHave you ever broken a bone? (list your age, date, and circumstances for every fracture below) No
Does your mother, father, brother, or sister have osteoporosis?	YesDoes your mother, father, brother, or sister have osteoporosis? Yes	NoDoes your mother, father, brother, or sister have osteoporosis? No
Has your mother, father, brother, or sister broken bone since age 40?	YesHas your mother, father, brother, or sister broken bone since age 40? Yes	NoHas your mother, father, brother, or sister broken bone since age 40? No
Do you smoke cigarettes?	YesDo you smoke cigarettes? Yes	NoDo you smoke cigarettes? No
Do you have more than two drinks of an alcoholic beverage per day?	YesDo you have more than two drinks of an alcoholic beverage per day? Yes	NoDo you have more than two drinks of an alcoholic beverage per day? No
Do you weigh less than 127 lbs?	YesDo you weigh less than 127 lbs? Yes	NoDo you weigh less than 127 lbs? No
Do you have rheumatoid arthritis?	YesDo you have rheumatoid arthritis? Yes	NoDo you have rheumatoid arthritis? No
Do you have kidney failure?	YesDo you have kidney failure? Yes	NoDo you have kidney failure? No
Have you had vitamin D deficiency?	YesHave you had vitamin D deficiency? Yes	NoHave you had vitamin D deficiency? No
Do you have lactoce intolerance?	YesDo you have lactoce intolerance? Yes	NoDo you have lactoce intolerance? No
Any difficuly with digestion?	YesAny difficuly with digestion? Yes	NoAny difficuly with digestion? No
Have you ever had hyperthyroidism (an overactive thyroid gland)?	YesHave you ever had hyperthyroidism (an overactive thyroid gland)? Yes	NoHave you ever had hyperthyroidism (an overactive thyroid gland)? No
Have you had hyperparathyroidism, or a high calcium level in your blood?	YesHave you had hyperparathyroidism, or a high calcium level in your blood? Yes	NoHave you had hyperparathyroidism, or a high calcium level in your blood? No
Do you have inflammatory bowel disease, such as Crohn's disease?	YesDo you have inflammatory bowel disease, such as Crohn's disease? Yes	NoDo you have inflammatory bowel disease, such as Crohn's disease? No
Do you have intestinal malabsorption, such as celiac disease?	YesDo you have intestinal malabsorption, such as celiac disease? Yes	NoDo you have intestinal malabsorption, such as celiac disease? No
Have you had a gastrectomy (part of your stomach removed)?	YesHave you had a gastrectomy (part of your stomach removed)? Yes	NoHave you had a gastrectomy (part of your stomach removed)? No
Have you ever had an eating disorder?	YesHave you ever had an eating disorder? Yes	NoHave you ever had an eating disorder? No
Have you had an organ transplant?	YesHave you had an organ transplant? Yes	NoHave you had an organ transplant? No
Have you fallen in the last year?	YesHave you fallen in the last year? Yes	NoHave you fallen in the last year? No
Do you have a walking or balance problem?	YesDo you have a walking or balance problem? Yes	NoDo you have a walking or balance problem? No
Do you have to push off on the arms of a chair to stand up?	YesDo you have to push off on the arms of a chair to stand up? Yes	NoDo you have to push off on the arms of a chair to stand up? No
Do you have any problems with infection or pain in your teeth or jaw?	YesDo you have any problems with infection or pain in your teeth or jaw? Yes	NoDo you have any problems with infection or pain in your teeth or jaw? No
Do you have any oral surgery or tooth extractions planned or scheduled?	YesDo you have any oral surgery or tooth extractions planned or scheduled? Yes	NoDo you have any oral surgery or tooth extractions planned or scheduled? No
Do you have any ongoing problems with your teeth or jaw?	YesDo you have any ongoing problems with your teeth or jaw? Yes	NoDo you have any ongoing problems with your teeth or jaw? No
Are you allergic to any medicines? (list below)	YesAre you allergic to any medicines? (list below) Yes	NoAre you allergic to any medicines? (list below) No