William A. Matarese, M.D.
342 Hamburg Turnpike, Ste. 205
Wayne, NJ 07470
Phone# (973) 595-7779 Fax (973) 595-0182

 

Last Name
 First
 Middle
Address
 City
 State

Zip
Home Phone Number

 Cell Phone Number
 Gender
Date of Birth
 Social Security Number
 Email Address
 
Referring Physician Phone Number
Primary Care Physician Phone Number
 
Employer Name
 Address
 Phone Number
 
In case of emergency please contact: Name Relationship
Home Phone Number

 Cell Phone Number
  
 
Pharmacy Name
 Phone Number
 Fax Number
 
If this is Workman’s comp or Motor vehicle related we need: claim# , adjuster name and phone# , insurance carrier ,
address where the billing will be sent to and date of accident . Please have this information available before your appointment date.
 
Insurance Information
Primary Insurance
 Address
ID Number
 Group Number
 Phone Number
Insured Name
 Date of Birth
 Social Security Number
 
Secondary Insurance
 Address
ID Number
 Group Number
 Phone Number
Insured Name
 Date of Birth
 Social Security Number
I consent to be examined by William A. Matarese, M.D. at each visit. I agree to allow him to release my records to the insurance carrier or its representative any information necessary to determine my benefits. I also assign payments to William A. Matarese, M.D. I understand that payment is required at the time of each visit/service unless otherwise agreed to with the billing department. I understand that I am responsible for all charges incurred regardless of any problem that may arise with the insurance.
Patient Signature- Electronic signature please type your name
 Date
 

Orthopedics Patient Health History

Patient Name
 Appointment Date
 Appointment Time
 
Are you taking any Medications?
If YES please list Medication and Dosage:
 
Are you allergic to any Medications?
If YES please list Medication Type and Reaction:
 
Non-Medication Allergies
Are you allergic to any non-medical things such as latex, metal or tape?
If YES please Specify:
Are you allergic to constant dye?
 
Surgeries and Hospitalizations
Have you ever had problems with anesthesia?
If YES please list:
Have you ever had surgery
If YES please list:
 
What is your current occupation? If retired please check here:
Which is your dominant hand?
 
Today's Problem
Location Severity : Please select ( 10 being the worst)
1
2
3
4
5
6
7
8
9
10
How long have you had this problem?
 Aggravating Factor:
Relieving Factor:
 

 

Patient Health History

1.
Are you allergic to any of the following?
   
Adhesive Tape
Iodine
Latex
Metal
Contrast Dye
   
2. Mark if you have been diagnosed with any of the following
 
Bone Cancer Tuberculosis
Breast Cancer Duodenal Ulcer
Colon Cancer Hepatitis, unspecified type
Lung Cancer Hepatitis, specified type
Prostate Cancer Arthritis unspecified type
Other Cancer Arthritis, Osteo
Heart Attack Arthritis, Rheumatoid
Heart Disease Anxiety
Hypertension Depression
Stroke Diabetes
Asthma Anemia
   
3. Mark family members that have been diagnosed with the following.
 
 
None
Mother
Father
Brother
Sister
Heart Disease
High Blood Pressure
Stroke
Asthma
COPD
Arthritis
Osteoporosis
Diabetes before age 18
Diabetes after age 18
Bleeding/Clotting Problem
   
4. Mark if retired:
   
5. Marital Status:
   
6. Do you use any of the following tabacco products? (Hold down CTRL to select multiple products)
 
   
7 Dependency or addiction to drugs now or in the past:
 
Amphetamines Hydrocodone
Barbiturates Marijuana
Cocaine Morphine
Codeine Oxycodine
Diazepam Soma
Heroin    
   
8. Do you now have or have you recently had any of the following?
 
Fatigue Painful joints
Fever Stiffness in joints
Unintentional weight gain Weakness
Unintentional weight loss Change in alertness
Blurred vision Drooping of one side of the face
Red Eye Headache
Sensitivity to light Loss of consciousness
Blackingout or fainting Severe facial pain
Chest pain Seizures
Irregular heartbeats Tingling
Frequent productive cough Feels nervous (anxiety)
Shortness of breath Feels Sad (depression)
Wheezing Trouble sleeping
Abdominal pain Appetite is increased
Nausea Fatigue(excessive)
Vomiting Neck has enlarged
Cramping Thirst is increased
Pain in Back Infections Recurring
Pain in Neck Severe reaction to an insect bite