Download Howard J. Gelb, M.D., P.A., F.A.A.O.S.

Howard J. Gelb, M.D., P.A., F.A.A.O.S.
Board Certified & Fellowship Trained in Sports Medicine & Orthopaedic Arthroscopic Surgery
Subspecialty Certified in Orthopaedic Sports Medicine
9980 Central Park Blvd North, Suite 222 Boca Raton, FL 33428
(P) 561-558-8898 (F) 561-558-8868
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 2nd 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
SS#:________________________
□Yes □No
Insured
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:__________________________
Howard J. Gelb, M.D., P.A., F.A.A.O.S.
Board Certified & Fellowship trained in Sports Medicine & Orthopaedic Arthroscopic Surgery
Subspecialty Certified in Orthopaedic Sports Medicine
9980 Central Park Blvd. North, Suite 222 Boca Raton, FL 33428
(P) 561-558-8898 (F) 561-558-8868
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
□
□Intermittent □Daily Duration of symptoms: □Constant □Hours □Minutes □Seconds
Do symptoms include? □Swelling □Weakness □Numbness □Decreased Motion □Pins & Needle Sensation □Other__________
Frequency of symptoms: Constant
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? ________________________
______________________________________________________________________________________________________________
□Ice treatment □Heat Treatment □Physical Therapy □Rest (Length of Time)____
□Injections (How Many?)____ □Medications □Related Past Surgeries for condition (Specify Procedure & Date)_______________
Past Treatment of your current problem:
____________________________________________________________________________________________________________
Howard J. Gelb, M.D., P.A., F.A.A.O.S.
Board Certified & Fellowship Trained in Sports Medicine & Orthopaedic Surgery
Subspecialty Certified in Orthopaedic Sports Medicine
9980 Central Park Blvd North, Suite 222 Boca Raton, FL 33428
(P) 561-558-8898 (F) 561-558-8868
Name:
Date:
REVIEW OF SYSTEMS: (Please check all that apply)
Constitutional
□Weight Gain
□Weight Loss
□Fever
□Chills
□Fatigue
Eyes
□Blurred Vision
□Cataracts
□Contact Lens
□Glaucoma
Ears, Nose Throat
□Hearing Loss
□Dry Mouth
□Nasal Congestion
□Sore Throat
□Tinnitus
□Loose Teeth
Cardiovascular
□Chest Pain
□Shortness of Breath
□Dyspnea on Exertion
□Angina
□Palpitations
□Intermittent Pain in Legs
□Swelling, Edema
Respiratory
□Cough
□Difficulty Breathing
□Wheezing
□Asthma
□Emphysema
□Breathing Treatment
Genitourinary
□Burning on Urination
□Blood in Urine
□Difficulty Voiding
□Kidney Stones
□History of UTI
Gastrointestinal
□Diarrhea
□Blood in Stool
□Nausea
□Vomiting
□Ulcers
□Food Intolerance
Integumentary
□Skin Lesions
□Rash
□Redness of Skin
□Moles
□Dry or Scaly Skin
Neurological
□Numbness
□Seizures
□Balance Problems
□Tingling
□Dizziness
□Difficulty Walking
□Bowl or Bladder Loss of Control
Musculoskeletal
□Joint Pain
□Rt □Lt
□Back Pain
□Neck Pain
□Shoulder Pain
□Hip Pain
□Knee Pain
□Ankle Pain
□Wrist Pain
□Elbow Pain
□Hand Pain
□Joint Stiffness
□Locking
□Swelling
□Giving Way
□Partial Giving Way
□Loss of Motion
□Pain with Motion
□Decreased Ability to Walk
□Difficulty Tying Shoes
□Difficulty Climbing Stairs
□Difficulty Sitting
□History of Orthopaedic Surgery
Type_________________________
Psychiatric
□Depression
□Anxiety
□Insomnia
□Addiction
□Drug Use
□History of Psychiatric Problems
Endocrine
□Thirst
□Frequent Urination
□Night Sweats
Hematological/Lymphatic
□Bleeding Problems
□Anemia
□AIDS
□Blood Clots
□Cancer
Site_____________________________
Name:
Date:
PAST MEDICAL HISTORY- Check all that apply
Drug Addiction
Asthma
□
□
□Emphysema
□Arthritis
□Epilepsy
□Anemia
□Fractures
□Blood Clots
□Gout
□Diabetes
□High Blood Pressure
□Cancer (type)______________________
□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
Tape
□
□Aspirin
□Codeine
□Iodine
□Other___________________________
MEDICATIONS
1.________________ 2.____________________
3.____________________
□Novacaine
4._____________________
5._______________________6.__________________________7._______________________
FAMILY HISTORY
Mother:
Alive
Father:
Brother:
Sister:
□
□Alive
□Alive
□Alive
SOCIAL HISTORY
Primary Language
□Deceased
□Deceased
□Deceased
□Deceased
Age:_____ Medical Conditions or Cause of Death:____________________
Age:_____ Medical Conditions or Cause of Death:____________________
Age:_____ Medical Conditions or Cause of Death:____________________
Age:_____ Medical Conditions or Cause of Death:____________________
□English
□Spanish □French □Portuguese
□
Single
Marital Status:
□Engaged □Married □Divorced
Alcohol Use:
□None
□Rare □Socially □Occasionally
Smoking History:
□Non-Smoker □Previous Smoker Packs per Day?_____
□Current Smoker Packs per Day?____ How Long?____
□Swimming
□Hockey
SPORTS: □Football □Baseball
□Soccer □Basketball □Rollerblading
□Karate
□Tennis □Running
□Dance □Golf □LaCrosse
□Snow-skiing
□Other:_________________
Other:_____________________
Widow
□
□Other:___________________
How Long?_________
□Skating □Wrestling
□Jujitsu □Cheerleading
Howard J. Gelb, M.D., P.A., F.A.A.O.S.
Board Certified & Fellowship trained in Sports Medicine & Orthopaedic Arthroscopic Surgery
Subspecialty Certified in Orthopaedic Sports Medicine
9980 Central Park Blvd. North, Suite 222 Boca Raton, FL 33428
(P) 561-558-8898 (F) 561-558-8868
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
Howard J. Gelb, M.D., P.A., F.A.A.O.S.
Board Certified & Fellowship trained in Sports Medicine & Orthopaedic Arthroscopic Surgery
Subspecialty Certified in Orthopaedic Sports Medicine
9980 Central Park Blvd. North, Suite 222 Boca Raton, FL 33428
(P) 561-558-8898 (F) 561-558-8868
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:
________________________________________________________________________