Board Certified & Fellowship Trained in Sports Medicine & Orthopaedic Arthroscopic Surgery 9980 Central Park Blvd North, Suite 222 Boca Raton, FL 33428 Please Print: Name (First): (MI) (Last) Date: Address: City: State: Zip: Home Phone: Cell Phone: E-mail: Driver s License #: Driver s License State: Occupation: DOB: Age: Sex: SSN#: Race: Ethnicity: Employer/School: Business Phone#: Address: City: State: Zip: Permanent Resident: Yes No If no, Please list 2 nd address Address: City: State: Zip: If patient is a minor- Please complete: Father s Name: Mother s Name: Employer: Employer: Position: Phone: Position: Phone: Please list the name of a person to contact in case of an emergency other than a spouse or parent: Name: Relationship: Phone: Address: City: State: Zip: PRIMARY INSURANCE- Please have Insurance cards ready to be copied Name of Company: Phone: Address: City: State: Zip: ID#: Group#: Insured s Full Name: Is this an Employer s Plan Yes No Insured SS#: Insured DOB: Relationship to insured :( self, spouse, child, other): SECONDARY INSURANCE-Please have Insurance cards ready to be copied Name of Company: Phone: Address: City: State: Zip: ID#: Group# Insured s Full Name: Is this an Employer s Plan Yes No Insured SS#: Insured DOB: Relationship to insured: (self, spouse, child, other): AUTHORIZATION FOR TREATMENT/RELEASE OF INFORMATION/FINANCIAL AGREEMENT: I give permission to administer treatment and perform tests as determined necessary by the physician in the diagnosis and treatment of my condition. Furthermore, I authorize the release of information relating to my medical treatment to my insurance company in order to process my claim services. I request that payments for insurance benefits made on my behalf, be paid directly to Dr. Gelb. I assume full financial responsibility for all bills associated with this office and all tests, treatments, x-rays etc., that are not covered by my insurance. Payment is expected at the time of service, including all applicable co-payments and deductibles. I further understand that it is my responsibility to get authorization from my Primary Care Physician or Insurance Company (if required by the insurance company) prior to services being rendered. I understand that no guarantee or assurance has been made as to the results of the procedure or treatment and that it may not cure the condition. Should this become a collection problem the patient assumes all costs of collection, including, but not limited to court costs, interest and legal fees. Patient s or Legal Guardian s Signature: Date:
Board Certified & Fellowship trained in Sports Medicine & Orthopaedic Arthroscopic Surgery 9980 Central Park Blvd. North, Suite 222 Boca Raton, FL 33428 Please Print: Name (First) (Last) Date: Age: Ht: Wt: Male Female Right Handed Left Handed Ambidextrous Occupation: How were you referred to our office? Who is your Primary Physician or Pediatrician? Phone #: HISTORY OF PRESENT ILLNESS Describe the condition that brought you to this office: Is your injury: Work Accident Auto Accident Slip & Fall Sports Related Other Related Injury Date when Accident/Injury occurred: Where did Accident/Injury Occur? Description of Accident/Injury: Contributing events or cause for symptoms: Describe the severity and quality of pain: (sharp, dull, stabbing, etc.) Circle rating of 1-10 for severity of symptoms with 10 being the greatest: 1 2 3 4 5 6 7 8 9 10 Frequency of symptoms: Constant Intermittent Daily Duration of symptoms: Constant Hours Minutes Seconds Do symptoms include? Swelling Weakness Numbness Decreased Motion Pins & Needle Sensation Other If applicable, is the joint? Popping Locking Clicking Instability/Giving way Other What activities worsen your condition? When do the symptoms occur? Morning Afternoon Evening During Exercise After Exercise Have you been previously treated for this accident/injury elsewhere? If yes, by whom? Past Treatment of your current problem: Ice treatment Heat Treatment Physical Therapy Rest (Length of Time) Injections (How Many?) Medications Related Past Surgeries for condition (Specify Procedure & Date)
Board Certified & Fellowship Trained in Sports Medicine & Orthopaedic Surgery 9980 Central Park Blvd North, Suite 222 Boca Raton, FL 33428 Name: Date: REVIEW OF SYSTEMS: (Please check all that apply) Constitutional Genitourinary Integumentary Weight Gain Burning on Urination Skin Lesions Weight Loss Blood in Urine Rash Fever Difficulty Voiding Redness of Skin Chills Kidney Stones Moles Fatigue History of UTI Dry or Scaly Skin Eyes Gastrointestinal Neurological Blurred Vision Diarrhea Numbness Cataracts Blood in Stool Seizures Contact Lens Nausea Balance Problems Glaucoma Vomiting Tingling Ulcers Dizziness Ears, Nose Throat Food Intolerance Difficulty Walking Hearing Loss Bowl or Bladder Loss of Control Dry Mouth Musculoskeletal Nasal Congestion Joint Pain Psychiatric Sore Throat Rt Lt Depression Tinnitus Back Pain Anxiety Loose Teeth Neck Pain Insomnia Shoulder Pain Addiction Cardiovascular Hip Pain Drug Use Chest Pain Knee Pain History of Psychiatric Problems Shortness of Breath Ankle Pain Dyspnea on Exertion Wrist Pain Endocrine Angina Elbow Pain Thirst Palpitations Hand Pain Frequent Urination Intermittent Pain in Legs Joint Stiffness Night Sweats Swelling, Edema Locking Swelling Hematological/Lymphatic Respiratory Giving Way Bleeding Problems Cough Partial Giving Way Anemia Difficulty Breathing Loss of Motion AIDS Wheezing Pain with Motion Blood Clots Asthma Decreased Ability to Walk Cancer Emphysema Difficulty Tying Shoes Site Breathing Treatment Difficulty Climbing Stairs Difficulty Sitting History of Orthopaedic Surgery Type
Name: Date: PAST MEDICAL HISTORY- Check all that apply Asthma Drug Addiction Arthritis Emphysema Anemia Epilepsy Blood Clots Fractures Diabetes Gout Cancer (type) High Blood Pressure Other Heart Disease HIV Liver Disease Psoriasis Peptic Ulcer Thyroid Disease PAST SURGICAL HISTORY - Check all that apply Appendectomy Heart Valve Replacement Arthroscopy Joint Replacement Back Surgery Neck Surgery Breast Surgery Pacemaker Carpal Tunnel Prostate Surgery Heart Bypass Other: ALLERGIES Penicillin Aspirin Codeine Iodine Novacaine Tape Other MEDICATIONS 1. 2. 3. 4. 5. 6. 7. FAMILY HISTORY Mother: Alive Deceased Age: Father: Alive Deceased Age: Brother: Alive Deceased Age: Sister: Alive Deceased Age: SOCIAL HISTORY Primary Language English Spanish French Portuguese Other: Marital Status: Single Engaged Married Divorced Widow Alcohol Use: None Rare Socially Occasionally Other: Smoking History: Non-Smoker Previous Smoker Packs per Day? How Long? Current Smoker Packs per Day? How Long? SPORTS: Football Baseball Swimming Hockey Skating Wrestling Soccer Basketball Rollerblading Karate Tennis Running Dance Golf LaCrosse Jujitsu Cheerleading Snow-skiing Other:
Board Certified & Fellowship trained in Sports Medicine & Orthopaedic Arthroscopic Surgery 9980 Central Park Blvd. North, Suite 222 Boca Raton, FL 33428 Please check all appropriate boxes: I, give permission to Howard J. Gelb, MD, or his staff to (Patient s name) leave any test results or exam results: Leave message on answering machine or fax at home Leave message with spouse or family member Leave message with (name of person) Leave message on voice mail at work Leave message with only myself by phone or fax I, give permission for my medical records to be faxed or (Patient s name) mailed upon request to: My Primary physician Any other physician or facility that will be involved with my care Dr. Howard Gelb My insurance carrier I, give permission to Dr. Gelb to discuss my medical (Patient s name) condition with: My spouse My children My parents Other I hereby authorize the release of any medical records necessary for Dr. Gelb to render medical services by signing a lifetime signature below: Signature Date
Board Certified & Fellowship trained in Sports Medicine & Orthopaedic Arthroscopic Surgery 9980 Central Park Blvd. North, Suite 222 Boca Raton, FL 33428 PATIENT CONSENT FORM The Department of Health and Human Services has established a "Privacy Rule" to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients' consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment payment of health care operations, in order to provide health care that is in your best interest. We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information, (PHI),If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objection to this form, please ask to speak with our HIPAA Compliance Officer. You have the right to review our privacy notice, to request restriction and revoke consent in writing after you have reviewed our privacy notice. Printed Name: Signature: Date: