• Patient Information
  • Acknowledgement and content
  • All-Pro Orthopedics and sports medicine PA
  • New Patient Medical History
  • Chief Complaint
  • History of Present Illness
  • Prior Testing / Treatment
  • Review of Systems
  • Family History
  • Social History
  • Pain Diagram

Patient Information

Patient Information

Who May we thank for referring you to us?

Please list the name of a person to contact in case of an emergency other than a spouse or parent

Primary Insurance

Secondary Insurance

Acknowledgement and consent

Read before signing the Acknowledgement and Consent

This acknowledgement of notice and consent authorizes ALL-PRO ORTHOPEDICS AND SPORTS MEDICINE P.A. to use health information about you for treatment, payment, and health care operations perposes.

NOTICE OF PRIVACY PRACTICES: ALL-PRO ORTHOPEDICS AND SPORTS MEDICINE P.A. has a Notice of Privacy Practices which describes how we may use your protected health information and how you can access your protected health information and exercise other rights concerning your protected health information. You may review our current notice prior to signing this acknowledgement and consent.

AMENDMENTS: We reserve the right to change our Notice of Privacy Practices and to make the terms of any change effective for all protected health information that we maintain, including information created or obtained prior to the date of the effective date of the change. You may abtain a revised notice by submittings a written request to our Privacy Officer.

How to contact our Privacy Officer

Mail: 17779 SW 2nd St, Pembroke Pines, FL 33029
Tel: 954-322-1110/Fax:954-322-1099

Acknowledgement and Consent

I have received the Notice of Privacy Practices for ALL-PRO ORTHOPEDICS AND SPORTS MEDI P.A.. They are authorized to use health information about (please print patient's name)

for treatment, payment, and healthcare operations purposes consident with its Notice of Privacy Practices.

Personal representative information (if applicable)

Identity of Recipents: Provide the name or other specific indentification of the person(s) or class of persons to whom the covered entity may disclose the covered information:

All-Pro Orthopedics and sports medicine PA

Assignment of Benefits: I

Do hereby IRREVOCABLY ASSIGN to the above-named medical provider, any right or benefits under my policy of insurance with

, for any service and/or charges provided by the above medical provider. Pursuant to this ASSIGNMENT OF BENEFITS, you are hereby directed to mail any and all checks directly and solely payable to the above named medical provider at the address listed on the HCFA-1500A form in box 33. As part of this ASSIGNMENT OF BENEFITS, I hereby instruct the insurance carrier that in the event the medical benefits are disputs for any reason, including medical reasonableness and/or necessity, that the amount of benefits claimed by ALL-PRO ORTHOPEDICS AND SPORTS MEDICINE PA is to be set aside and not disbursed until the dispute is resolved.

Personal Injury Protection - Initial Treatment or Service Provided

Letter of protection

The undersigned paitent ("Patient") authorizes All-Pro Orthopedics ans Sports Medicine P.A. ("The Provider") to furnish the undersigned attorney ("Attorney") a full report of examination, diagnosis, treatment, operation and/or prognosis, as filed by the Patient\'s doctor with respect to health care services and procedures that Patient received or may be receiving the furture with Provider (in the aggregate, "Services") and Provider\'s bill for services ("the Bill") as related to injury(s) that the Patient sustained as the result of an accident that occurred on

(date of accident) (the "Accident"). With respect to the Provider providing such services to Patient:

New Patient Medical History Form

New Patient Medical History Information

Caucasian African American Hispanic other
Hispanic Non-Hispanic other
English Spanish Chinese other

New Patient Medical History Form - Chief Complaint

Chief Complaint

Right Left Ambidextrous
Pain Numbness/Tingling Fracture Stiffness Other
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Right Left
Pain radiates from/to: (ex. from low back to right leg)

New Patient Medical History Form - History of Present Illness

History of Present Illness

1. Is your problem the result of an injury or accident

No Injury Injury Injury at Work Auto Accident Sport Injury Prior Surgery
Acute (sudden) Chronic condition (> 3 months)

2. Are you represented by an attorney

Yes No
Yes No

3. Have you had a problem like this before?

Yes No

4. Have you been seen in an ER?

Yes No

5. Race the pain (10 being the most pain):

1 2 3 4 5 6 7 8 9 10

6. Do the symptoms wake you from sleep?

Yes No

7. Please describe the symptoms:

Sharp Dull Stabbing Throbbing Aching Burning Shooting

8. What is the timing of the symptoms?

Constant Intermittent (comes and goes)

9. Is the problem getting better or worse?

Getting better Getting worse Unchanged

10. What makes the symptoms worse?

Squatting Kneeling Sitting Bending Stairs Twisting Moving Lying in bed Running Walking Athletics Standing Gripping Lifting Reaching Overhead

11. Are there any other symptoms associated with this problem?

Redness Bruising Swelling Numbness Stiffness Limping Clicking Locking Popping Tingling Weakness Giving way

New Patient Medical History Form - Prior Testing / Treatment

Prior Testing / Treatment

How you had any prior tests?

None X-rays MRI CT Scan Never Test (EMG/NCV) Bone Scan

How you had any prior treatment for this problem?

Yes No

Type of treatment

Ice
Heat
Rest
NSAIDs
Muscle Relaxers
Chiropractor
Physical Therapy
HomeExerciseProgram
Surgery
Injections
Bracing
TENS unit

Status of symptoms after treatment (select only those that apply)

Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged
Improved Worsened Unchanged

Date of treatment

Other/Comments

Select all previous Hospitalizationa/surgeries: None

Aneurysm (Brain) Surgery
Aortic Bypass / Vascular Surgery
Appendectomy
Cataract (Eye) Surgery
Cholecystectomy (Gallbladder)
Heart Surgery
Hernia Repair
Hysterectomy
LAP Band / Gastric Bypass Surgery
Lumpectomy
Mastectomy
Malignancy/Cancer
Stents
Orthopedic on side:
Right
Left
Arthroscopy: Knee
Arthroscopy: Shoulder
Carpal Tunnel Release
Rotator Cuff Repair
Total Hip Replacement
Total Knee Replacement
Total Shoulder Replacement
Spinal Surgery - Indicate Level:

Other Surgery

Other Orthopedic Surgery

New Patient Medical History Form - Review of Systems

Medical Questions

Mark all that currently apply:

Meta in body Claustrophobic Pregnant Sleep Apnea Uses a CPAP Snores

Are you talking blood thinners:

Yes No

Review of Systems

Please indicate if you have experienced any of the following symptoms in the last 6 months?
Heartburn, Ulcers Nausea, Vomiting Blood in Stool
Fever HeatorColdIntolerance Night Sweats
Weight Loss Loss of Appetite Fatigue
Blurred Vision Double Vision Vision Loss
Hearing Loss Hoarseness Trouble Swallowing
Chest Pain Palpitations
Chronic Cough Pneumonia Shortness of Breath
Painful Urination Blood in Urine Kidney Problems
Frequent Rashes Skin Ulcers Lumps Psoriasis
Frequent Falls Loss of Coordination Numbness Change in Bowel Change in Bladder Dizziness
Depresion/Anxiety Drug/AlcoholAddiction Sleep Disorder
Easy Bleeding Easy Bruising Anemia
None of all
None
Comment

New Patient Medical History Form - Family History

Family History

Have any direct relatives had any of the following disorders? None for all

None
Bleeding Problems
Stroke
Diabetes
Epilepsy
Osteoporosis
Heart Disease
Connective Tissue
Rheumatoid Arthritis
Hypertension
Muscular Dystrophy
Cancer
Comments (ex. Cancer type)
None
Bleeding Problems
Stroke
Diabetes
Epilepsy
Osteoporosis
Heart Disease
Connective Tissue
Rheumatoid Arthritis
Hypertension
Muscular Dystrophy
Cancer
Comments (ex. Cancer type)
None
Bleeding Problems
Stroke
Diabetes
Epilepsy
Osteoporosis
Heart Disease
Connective Tissue
Rheumatoid Arthritis
Hypertension
Muscular Dystrophy
Cancer
Comments (ex. Cancer type)

New Patient Medical History Form - Social History

Social History

Do you use tobacco?

Daily Occasionally Former smoker Never Unknown

Do you drink alcohol?

Daily Occasionally Rarely Never

Marital Status:

Married Single Divorced Windowed Domestic Partnership

Are you currently working?

Yes No Retired Disabled

If no, what date did you last work?

Please list work restriction, if any:

Student

New Patient Medical History Form - Pain Diagram

Pain Diagram

Do you have any allergies? Yes No

If Yes, Please list below:

Medication, Relevant Food, or "Seasonal"

Reaction

Latex allergy? Yes No

Please list all medications you take on a regular basis: None

Medication

Dosage and Frequency (e.g. 20 mg, once/day)

Do you have a personal history of any of the following? None

Aneurysm Where:
Angina (Chest Pain)
Arthritis Type:
Asthma
Bone or Joint Infections
Cancer Type:
Chemotherapy / Radiation
COPD
Congestive Heart Failure
Diabetes Type:
Emphysema
Epilepsy
Heart Attack
Hepatitis Type:
HIV / AIDS
High Cholesterol
Hypertension
Hyperthyroidism
Hypothyroidism
Last A1C:
Kidney Disease
Kidney Stones
MRSA Infection
Pacemaker
Phlebitis (Blood Clots)
Pulmonary Embolism
Reaction to Anesthesia Type:
Seizures
Stomach Ulcers
Stroke / TIA
Tuberculosis

Please list any other conditions or details of conditions marked above:

After click Submit button, your form will be sent to "All Pro Orthopedic & Sports Medicine", also please check your email to have one pdf version of the form. Thank you very much.