What is your name

What Is Your Name?

How Old Are You?

Are You Male Or Female? MaleFemale

What Is Your Date Of Birth?

What Is Your Social Security Number, Driver's License and State of Licensure?

SSN:Driver License:State of Licensure:

What Is Your Address?

Address:City:State:
Zipcode:

What Is Your Occupation and Phone Number?

Occupation:Cell Phone:Work Phone:

Were You Referred Here By Another Physician?

If yes, please enter Doctor’s Name:

Please Check The Boxes That Describe The Main Problem That You Are Having: Pain Swelling Stiffness Numbness Other:
Where Are You Having Your Main Problem?
Location	Right	Left	Both
Shoulder
Arm
Elbow
Forearm
Wrist
Hand
Pelvis
Hip
Thigh
Knee
Leg
Ankle
Foot
Neck
Upper Back
Lower Back
Other:
Other:

On what date did your injury occur or symptoms appear?

Is Your Main Problem Caused By:

Work RelatedAuto AccidentWork Related Auto AccidentOffshore InjurySlip and FallOther

If you were in an automobile accident, where you a driver, passenger or pedestrian?

DriverPassengerPedestrian

Where you using a seatbelt? YesNo

What was your vehicle?

AutoTruckSUV18-wheelerVanMotorcycle Other:

What was the other vehicle?

AutoTruckSUV18-wheelerVanMotorcycle Other:

What part of your vehicle was hit? Driver SidePassenger SideHead OnRear EndedT-BonedWas T-Boned By

Did you go to a hospital after the accident?

Hospital Name:

What treatment did you receive?

X-rayed, Medicated, Treated, ReleasedMedicated, Treated, ReleasedTreated and ReleasedAdmitted

What is your current status?

ImprovedSomewhat ImprovedNot Improved

What is your degree of satisfaction with your current condition?

HappySomewhat HappyUnhappy

What Treatment Have You Had For Your Problem?

Treated Self Physical Therapy Medicines Surgery None

Other:

Have You Seen Another Physician For Your Problem?

If so, please enter your physician’s name:

*Besides your Main Problem, please describe any OTHER PROBLEMS* that you are having:**
Location:	Type of Problem:	Side:	Duration:
Shoulder:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears Unknown
Arm:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears Unknown
Elbow:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Forearm:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Wrist:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Hand:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Pelvis:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Hip:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
*Besides your Main Problem, please describe any OTHER PROBLEMS* that you are having:**
Thigh:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Knee:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Leg:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Ankle:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Foot:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Neck:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Upper Back:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Lower Back:	PainSwellingStiffness Other:	RLBoth	DaysWeeksMonthsYears
Other:	PainSwellingStiffness Other:	RLBoth Does Not Apply	DaysWeeksMonthsYears
Other:	PainSwellingStiffness Other:	RLBoth Does Not Apply	DaysWeeksMonthsYears

Are you taking any medicine?

Name of Medicine	Amount or Dose	Frequency or How Often

Do You Have An Allergy to Any Medicines?

Name of Medicine	How Do You React

Do You smoke? No Yes Packs/day Number of years

Do You Drink Alcohol? No Yes Drinks/day Number of years

Do You Use Drugs? No Yes Daily Weekly Monthly Number of years

Martial Status? Married Single Widow(er) Divorced Separated

Children No Yes Number

Employment? Unemployed Homemaker Part-time Full-timeDisabledRetired Other:

Other than your main problem, do you have any of the following problems:	YES	NO	DURATION
Early morning stiffness?			DaysWeeksMonthsYears
Early morning swelling?			DaysWeeksMonthsYears
Early morning pain?			DaysWeeksMonthsYears
Generalized joint and muscle pain?			DaysWeeksMonthsYears
Muscle pain in the shoulders and thighs?			DaysWeeksMonthsYears
Muscle weakness? Location:			DaysWeeksMonthsYears
Fatigue?			DaysWeeksMonthsYears
Skin rash?			DaysWeeksMonthsYears
Psoriasis?			DaysWeeksMonthsYears
Other than your main problem, do you have any of the following problems:	YES	NO	DURATION
Hair loss?			DaysWeeksMonthsYears
Ulcers in your mouth or nose?			DaysWeeksMonthsYears
Dry mouth?			DaysWeeksMonthsYears
Dry eyes?			DaysWeeksMonthsYears
Rash especially on the face?			DaysWeeksMonthsYears
Painful color changes in your hands when cold?			DaysWeeksMonthsYears
Problems with gout?			DaysWeeksMonthsYears
Heart or lung inflammation?			DaysWeeksMonthsYears
Emotional conditions?			DaysWeeksMonthsYears
Back problems, including disk or spine?			DaysWeeksMonthsYears
Lung problems, such as asthma, chronic bronchitis, or emphysema?			DaysWeeksMonthsYears
High blood pressure (hypertension) requiring medication?			DaysWeeksMonthsYears
Heart problems, such as angina, heart failure or enlarged heart, using a cardiac pacemaker, bypass surgery?			DaysWeeksMonthsYears
Hardening of the arteries in one or both legs (athersclerosis)?			DaysWeeksMonthsYears
Major paralysis or neurologic problems, such as stroke, multiple sclerosis, muscular dystrophy?			DaysWeeksMonthsYears
Diabetes?			DaysWeeksMonthsYears
Cancer diagnoses within the last 3 years (except skin cancer)?			DaysWeeksMonthsYears
Ulcer (duodenal, stomach, or duodenal)?			DaysWeeksMonthsYears
Kidney disease?			DaysWeeksMonthsYears
Any bleeding problems?			DaysWeeksMonthsYears
Trouble seeing even with glasses or contact lenses?			DaysWeeksMonthsYears
Previous miscarriages?
Blood clots?
Amputation of an arm or leg?

Please list below any previous illnesses that you have had:

Have you ever had surgery? YesNo
Type of Surgery	Year of Surgery	Type of Surgery	Year of Surgery
1.		2.
3.		4.
5.		6.
7.		8.
9.		10.

Please list below any health problems that your family has or had:
YOUR FATHER (Alive?YesNo)	Heart Lung Kidney Liver Brain	Cancer Diabetes Lupus Other Other
YOUR MOTHER (Alive?YesNo)	Heart Lung Kidney Liver Brain	Cancer Diabetes Lupus Other Other

Jeffrey D. Reuben, M.D., PhD., P.A.
Orthopaedic Surgery

4151 Southwest Freeway, Suite 260
Houston, TX 77027

Phone 713/521-7870

Fax 713/521-7919

Email jr@nmis.com

Patient Name:_____________________________________ Date:__________________

CONSENT FOR SERVICES:

I request, authorize, and give consent for Jeffrey D. Reuben, MD, PA (hereafter referred to as the “Provider”) to provide me with services and/or products. I understand that any services and/or products to be provided by Provider will be requested by my physician and will be provided under his direct supervision.

CONSENT FOR RELEASE OF MEDICAL INFORMATION:

I hereby authorize and given my consent to my physicians, and/or any holder of medical or other information about myself, to release any and all said information to Provider and its agents, employees and representatives.

CONSENT FOR RELEASE OF MEDICAL RECORDS TO INSURANCE CARRIER:

I hereby authorize and give my consent for Jeffrey Reuben, MD, PA, to furnish to my insurance carrier(s) or its agent(s), any information regarding my illness and/or therapy and agree to hold them harmless from any and all liability from same.

CONSENT FOR RELEASE AND USE OF MEDICAL INFORMATION:

I hereby authorize and five my unconditional consent to Provider, its employees and agents to release any medical and other information about myself to any local, state or federal health care regulatory bodies, private health care accrediting organizations with which Provider, is affiliated or seeks affiliation or to representatives of Provider’s Continuous Quality Improvement Committee.

IRREVOCABLE ASSIGNMENTS AND FINANCIAL RESPONSIBILITY:

In consideration of services rendered and to be rendered, I hereby irrevocably assign and transfer to Jeffrey D. Reuben MD, PA (hereinafter referred to as the "Provider"), all right, title and interest in all benefits payable for the health care rendered, which are provided in any and all insurance policies, employee benefit plans, and/or third party actions against any other person or entity from whom my dependents or I are entitled to recover (hereinafter referred to as "Benefits"). I further hereby irrevocably assign and transfer to the Provider all right, title and interest in any and all causes of action against all Insurance companies, employee benefit plans, third party administrators and/or other persons or entities responsible for payment of the Benefits (hereinafter referred to as "Responsible Parties"), I hereby appoint the Provider as my attorney in fact, with power of substitution, to sue or otherwise obtain payment of Benefits from the Responsible Parties. Said Irrevocable assignment and transfer shall be for the purpose of granting the Provider and Independent right of recovery against such Responsible Parties, but shall not be construed to be an obligation of the Provider to pursue any such right of recovery. I further authorize all Responsible Parties, to pay directly to Jeffrey D. Reuben, MD, PA all Benefits and amounts due for services rendered by the Provider. I understand that if the Provider Iis not paid In full by proceeds of any Benefits, then this assignment does not release my obligation and liability to the Provider for payment of all services and items provided to me or the above referenced patient, by the Provider. In the event no Benefits are paid by the Responsible Parties, then I agree to pay Jeffrey D. Reuben, MD, PA for all charges in excess of the Benefits paid. All payments will be made to Jeffrey D. Reuben, MD, PA at 4126 Southwest Freeway, Suite 700, Houston, Texas, 77027. The terms and consequences of these Irrevocable assignments and financial responsibilities have been fully explained to me to my understanding, or other individual(s) authorized to endorse this document in my behalf, and I have signed this document freely and without inducement other than the rendition of services by the Provider.

OTHER:

If the patient is unable to execute document, explain reason and attach power of attorney letter of guardianship or other written document evidencing power of attorney letter of guardianship or other written document evidencing power to bind patient; A duplicate copy of this document shall be accepted as original.

_________________________________ ___________ __________________

Signature of patient or representative Date Witness

_________________________________ ___________ __________________

Signature of patient or representative Date Witness