ABOUT YOUR VISIT TODAY – PLEASE READ THIS FORM CAREFULLY.

You have been sent here to have an orthopaedic medical examination performed by Doctor Goldstone in order to determine whether there are residuals of a specific accident, and, if so, how severe they are, how they might affect various aspects of your life, and whether or not they are of a permanent nature. There may be other things that the doctor needs to know in order to prepare his report on your case.

Therefore Dr. Goldstone must perform a complete examination as it pertains to your injuries, and that will begin with the taking of a medical and an accident history. You might feel that the form contains questions about your past medical history that you believe to be unimportant or unrelated. Nevertheless, it is absolutely important that you answer all of the questions on the form, as well as those that might be put to you verbally by the doctor or his assistants. Do not leave any blank spaces.

You will also be asked to fill out a “Pain Diagram”. NO ONE but the person being examined may mark this. Please read the instructions, and put the proper marks on the drawing, showing areas where you are still experiencing symptoms.

If you do not understand anything on the form, the staff will be happy to assist you. Feel free to ask for more paper if you need it. You will fill out the form in pencil, in case you need to make any erasures. We will never change what you have written, and any entries made by the doctor or staff will be in ink, for identification.

If you do not wish to provide the necessary information, you will not be examined today. The lawyers will be contacted, and you will eventually be advised what to do next.

We make every effort to see patients promptly. However, every individual’s needs are different, some people arrive late for their appointments, and some evaluations are more difficult than others. Therefore, we cannot always be on schedule, and you might have to wait longer than either you or we would have liked. We apologize in advance for any inconvenience. These delays are not intentional.

If you brought reports or imaging studies, make sure that they are given to the doctor for him to review

When the history is complete you will be weighed, and taken to an examining room. Unless your complaints are limited to only the forearms and/or feet, you will be asked to disrobe, leaving on only your undergarments. You will be given an examining gown, open in the back. The belt is stretchable – please tie it. If you have complaints such as back, spine or hip problems, Dr. Goldstone’s examination will include observations of your back as you move, and evaluate the tone of your back muscles with his hands. The staff will be nearby, and coming into the examining room periodically, unannounced. If you are a woman and prefer to have a female member of the staff present in the room during the physical examination, please make that request.

If anything during the examination causes pain, say so immediately !

Dr. Goldstone will be dictating a large part of his examination report while he is with you. There is a dictating microphone on the table. It makes a buzzing sound when it is not taping. When Dr. Goldstone wishes to dictate, he steps on the foot pedal, and the buzzing stops. You are NOT being taped (unless you talk at the same time that the doctor is dictating). If you hear him say something wrong, wave your hand, the doctor will stop dictating, and make any necessary corrections.

In order to create a permanent record of some aspects of the examination, it might be necessary to obtain photographs that shall be made a part of your medical file.

Upon completion of the examination, you are free to leave the office after getting dressed. Please leave the examining room door open. You do not need to stop at the desk. We hope that your experience here today will have been satisfactory. My staff and I welcome your comments.

I understand that no “Doctor-Patient” relationship exists, and that I am here only to be examined for the purpose of my lawsuit. I have read this form and agree to the examination procedures described:

Signed:_______________________________ Date:_______________200__