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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: ________________________________________________________________________