MEDICAL HISTORY PATIENT INFORMATION Name: Birth date: PAST MEDICAL HISTORY Head Trauma/TBI DVT/Blood Clot Heart Attack Other heart disease: ______________ Diabetes: Type 1 Type 2 Asthma COPD Hepatitis Jaundice Ulcer Kidney Disease Arthritis Rheumatoid Arthritis Gout Skin Condition/Hives Epilepsy Seizures Stroke Thyroid Disease Anemia Cancer: _______________ (please describe what type) Do you have any other disease or condition you think that we should know about? If yes, please explain: ALLERGIES None Penicillin Sulfa Cortisone Iodine Codeine Aspirin Other: ______________ Reaction(s): _________________________________________________________________________________ SOCIAL HISTORY Tobacco Use: Every Day Occasionally Former Smoker Never Smoker Other: ______________ Alcohol Use: Daily Frequently Occasionally History of Alcoholism Do Not Drink PAST SURGICAL HISTORY (PLEASE LIST) HOSPITALIZATIONS (PLEASE LIST) FAMILY MEDICAL HISTORY Please select all that apply: Mother: Alive Deceased Diabetes Heart Problems Stroke Hypertension Cancer: _________ (please describe what type) Other: ____________ Father: Alive Deceased Diabetes Heart Problems Stroke Hypertension Cancer: _________ (please describe what type) Other: ____________ Patient/Guardian Signature Date
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MEDICAL HISTORY PATIENT INFORMATION
Name: Birth date:
PAST MEDICAL HISTORY
Head Trauma/TBI
DVT/Blood Clot
Heart Attack
Other heart disease: ______________
Diabetes: Type 1 Type 2
Asthma
COPD
Hepatitis
Jaundice
Ulcer
Kidney Disease
Arthritis
Rheumatoid Arthritis
Gout
Skin Condition/Hives
Epilepsy
Seizures
Stroke
Thyroid Disease
Anemia
Cancer: _______________ (please describe what type)
Do you have any other disease or condition you think that we should know about? If yes, please explain:
Tobacco Use: Every Day Occasionally Former Smoker Never Smoker Other: ______________
Alcohol Use: Daily Frequently Occasionally History of Alcoholism Do Not Drink
PAST SURGICAL HISTORY (PLEASE LIST)
HOSPITALIZATIONS (PLEASE LIST)
FAMILY MEDICAL HISTORY
Please select all that apply:
Mother: Alive Deceased
Diabetes Heart Problems Stroke Hypertension
Cancer: _________ (please describe what type) Other: ____________
Father: Alive Deceased
Diabetes Heart Problems Stroke Hypertension
Cancer: _________ (please describe what type) Other: ____________
Patient/Guardian Signature Date
APPOINTMENT REASON
PATIENT INFORMATION
Name: Birth date:
ORTHOPEDIC EVALUATION
Is your injury auto related? Is your injury work related? If Yes, what date did the injury occur?
Yes No Yes No
What are you being seen for today? Which side is affected?
Right Left Bilateral
Date of injury or start of pain: How did the pain occur?
Injury Chronic Spontaneous
If you sustained an injury, where and how did it occur?
PAIN DESCRIPTION
Quality of your pain?
None Mild Chronic
Type of pain?
Sharp Dull
Other _________________
Pain Level:
(1-3 Mild, 4-7 Moderate, 8-10 Severe)
0 1 2 3 4 5 6 7 8 9 10
TREATMENT INFORMATION
Have you seen another physician for this injury?
Yes No
If Yes, Who and When?
What treatments have you tried?
P.T. Brace Icing Injections
Surgery (if so please specify): _____________________________________
Other: _____________________
Have you had any testing?
X-Ray
MRI
EMG/NCS
Bone/CAT Scan
Other: _________________________
PRIMARY CARE PHYSICIAN
Name: Phone: Fax:
Patient/Guardian Signature Date
PATIENT INFORMATION
Name: Birth date:
DAILY MEDICATIONS
Please check box if give consent for us to retrieve your medication history for the last 18 months from an online database. We may still need to verify your medication history with you.
Prescription Name: Dosage: Frequency:
Prescription Name: Dosage: Frequency:
Prescription Name: Dosage: Frequency:
Prescription Name: Dosage: Frequency:
Prescription Name: Dosage: Frequency:
Prescription Name: Dosage: Frequency:
MINOR: LEGAL GUARDIAN AND/OR POWER OF ATTORNEY
(Note: POA must be accompanied by proper documentation, please see the receptionist.)
Name: Relationship to patient: Birth Date: Home phone no.:
Address (if different):
CONSENT FOR TREATMENT, AUTHORIZATION OF BENEFITS & INFORMATION RELEASE
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician or their designee for services rendered. I understand that I am financially responsible for any balance. I also authorize Lederman
Kwartowitz Center for Orthopedics & Sports Medicine or insurance company to release any information required to process my claims. I consent to evaluation, diagnosis, and/or treatment of the medical condition that I am presenting for. I give consent and
authorize my provider to order and/or perform all exams, tests, procedures and any other care deemed necessary or advisable for the evaluation, diagnosis and treatment. I understand that this consent is valid for each visit and I may revoke this authorization in
writing at any time in writing.
Patient/Guardian Signature Date
HIPAA Compliance Patient Consent Form
Please note: This is an abbreviated version of our Notice of Privacy Practices (HIPAA). You may request a full copy at any
time.
This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability
Act of 1996 (HIPAA). HIPAA is about individual privacy, and you should read this document carefully. It describes how we
may use and disclose your protected health information for purposes of treatment, payment or health care operations,
and for other purposes that are permitted or required by law. It also describes your rights to access and control your
protected health information.
We understand that medical information about you and your health is personal. We are committed to protecting health
information about you. We are required by law to:
▪ Ensure protected health information that identifies you is kept private; ▪ Give you this notice of our legal duties and privacy practices regarding your protected health information; and ▪ Follow the terms of the notice that is currently in effect. ▪ Notify you in the event of a breach of your PHI.
We reserve the right to revise or change the terms of our Notice of Privacy Practices at any time. You may also request a copy of the current Notice of Privacy Practices at any time. The following categories describe some of the different ways in which we may use or disclose your PHI without your authorization: Treatment, Payment, Health Care Operations, Appointment Reminders, Treatment Options, Health-Related Benefits and Services, Personal Representatives, Individuals Involved in your care and/or Business Associates (such as a lab or MRI facility). Our practice may also disclose your PHI in the following situations without your authorization: Public Health Risks, Abuse and Neglect, Legal Proceedings, Health Oversight Activities, Law Enforcement, Research, Military and/or Workers’ Compensation. I consent to the disclosure of my PHI to the following family member(s) or person(s) involved in my care:
