PATIENT INFORMATION

NAME: __________________________________ DOB: __________________AGE:___________

ADDRESS: _____________________________________________________________________

CITY: ____________________________________STATE:_________________ZIP:____________

HOME PHONE: ______________________ CELL: __________________ WORK: _____________

*Please list your email address for the patient portal. It will not be used for any commercial

communication. ________________________________________________________________

RACE: (Please circle one) American Indian or Alaska Native, Asian, Native Hawaiian or Other

Pacific, Black or African American, Caucasian, Hispanic, Other Race, Other Pacific Islander,

Refuse to Report

ETHNICITY: (Please circle one) Hispanic or Latin, Not Hispanic or Latin, Refuse to Report

LANGUAGE: (Please circle one) English, Indian (includes Hindi and Tamil), Spanish, Russian, &

other

PHARMACY NAME: __________________PHONE: _______________FAX:__________________

PHARMACY ADDRESS: ___________________________________________________________

CITY: ____________________________STATE:___________________ZIP:__________________

PHYSICIAN INFORMATION

PCP NAME: (FIRST) ______________________________ LAST: _________________________

ADDRESS: _____________________________________________________________________

CITY: __________________________STATE:__________________ZIP:_____________________

PHONE: ________________________

REFERRED BY: (FIRST) ______________________________LAST: _________________________

REFERRERS’S ADDRESS: __________________________________________________________

CITY: ____________________________STATE: _______________ZIP: _____________________

PHONE: __________________________ Family Friend M.D Other

INSURANCE INFORMATION

PRIMARY INSURANCE: _____________________________________ID #:__________________

SUBSCRIBER: _____________________ DOB: _________________RELATIONSHIP: ___________

SECONDARY INSURANCE: ___________________________________ID #:__________________

SUBSCRIBER: _____________________ DOB: _________________RELATIONSHIP: ___________

FUTURE APPOINTMENT REMINDERS: (Please check preference below)

PHONE (#) ___________________ TEXT (#) ___________________

MUST CIRCLE YES OR NO

*IS INJURY WORK RELATED? YES NO

*IS INJURY MOTOR VEHICLE RELATED? YES NO

*I GIVE MY PERMISSION FOR HAND SURGICAL ASSOCIATES, INC TO ACCESS MY MEDICATION

LIST FROM AN EXTERNAL SOURCE YES NO

I, the undersigned, verify that the information listed above is true and accurate to the best of

my knowledge. Any changes to the information listed have made and initialed.

RELEASE OF INFORMATION AUTHORIZATION: I, the undersigned, authorize the release of any

information required in the course of treatment to my insurance carrier or other health

provider I am consulting.

ASSIGNMENT OF BENEFITS AUTHORIZATION: I, the undersigned, assign to the provider(s) or

supplier all insurance payments for the medical services rendered. I also acknowledge

responsibility for payment of all medical fees in the event they are not paid by my insurance

plan.

______________________________________ ____________________________

Signature Date

If the patient is a minor please provide your name and relationship to the patient

NAME: (Please print) ____________________________________________________________

RELATIONSHIP TO PATIENT: _______________________________________________________

Hand Surgical Associates Paul Feldon, MD 125 Parker Hill Ave Hervey Kimball, MD

Boston, MA 02120 Edward Nalebuff, MD

617 738-0857 Andrew Terrono, MD

Health Questionnaire

Please answer all questions completely and/or check appropriate boxes Date: _____/_____/____

Name: ____________________________________ Person completing form: Self Other

Date of Birth: _____/_____/_____ Name/Relation: ______________

Height: ___________Weight: ___________ Are you right or left handed? Right Left

Ambidextrous

Current Occupation: ____________________________

Prior Occupations: _____________________________

Education completed: Technical school, High school, College, Graduate school

Describe your main problem:__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Did you have an injury? Yes No If so how / when?_____________________________________

Which side is affected? Right Left Both If both, which is worse? Right Left

When did it start? _____________________________________

What makes it better? _________________________________________________________________

_________________________________________________________________

What makes it worse? _________________________________________________________________

_________________________________________________________________

At night is it? Better Worse No change

Describe pain (if present): Burning Sharp Radiating (to: _________) Constant Intermittent

Pain location: Neck Shoulder Arm Elbow Forearm Wrist Hand __________

Have you ever had similar symptoms? Yes No If yes, when? _________________________________

Have you seen any other doctors for this problem? Yes No

If yes, please list: _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

(please bring all your medical records regarding this problem)

Please mark the treatment or tests you have had for this problem

X-rays

Arthrogram

CT scan

MRI

EMG/NCV (nerve test)

Myelogram

Hand therapy

Occupational therapy

Physical therapy

Acupuncture

Pain clinic treatment

Nerve block

Trigger point injection

Cortisone injection

Chiropractic treatment

(please bring all the results and actual x-ray films or CD for this problem)

Is your problem work related: Yes No Are you currently working? Yes No

If No: When did you last work? _____/_____/______

Do you have an attorney for this current problem? Yes No

(Please complete other side)

Health Questionnaire: Medical History (page 2)

Do you have any allergies to medicines? No Yes

Please list (if yes) :

Are you allergic to penicillin? No Yes Allergic to latex? No Yes

Are you taking any medication? No Yes (you may add extra sheets as needed)

Please list (if yes) :

Are you taking blood thinners? No Yes : name ____________________________

Have you had any operations? No Yes (you may add extra sheets as needed)

Please list (if yes) :

Do you smoke tobacco? No Yes If yes, how much and kind? ___________________ # years ______

Do you drink alcohol? No Yes If yes, how much and kind? ___________________ # years______

Are you pregnant? No Yes Possibly N/A

Do you have any of the following problems?

Heart arrhythmia No Yes Gall bladder No Yes Lung disease No Yes

Heart attack No Yes Bowel No Yes Asthma No Yes

High blood pressure No Yes Kidney No Yes Emphysema No Yes

Aortic or Mitral valve No Yes Bladder No Yes Tuberculosis No Yes

Chest pain No Yes Diabetes No Yes Infectious disease No Yes

Pacemaker No Yes Thyroid No Yes Hepatitis No Yes

Circulation problem No Yes Arthritis No Yes Liver disease No Yes

Stroke / TIA No Yes Gout No Yes Bleeding disorder No Yes

Blood clot No Yes Rheumatic fever No Yes Healing No Yes

Seizures

Anesthesia problems

No Yes

No Yes

Anxiety / Nervousness

Depression

No Yes

No Yes

Cancer

Type:

No Yes

Within the past year, have you had any of the following?

Fever / Chills No Yes Shortness of breath No Yes Chest pain No Yes

Weight loss or gain > 10 lbs No Yes Nausea / Vomiting No Yes Numbness or tingling No Yes

Visual changes No Yes Ear / Nose / Throat problem No Yes Fractures (broken bones) No Yes

Headaches No Yes Skin problem No Yes Back pain No Yes

Dizziness / Fainting No Yes Bleeding problem No Yes Anxiety / Depression No Yes

Do you have a family history of any of the following problems?

Heart disease No Yes Bowel disorder No Yes Vascular disease No Yes

Heart attack No Yes Kidney disorder No Yes Stroke / TIA No Yes

Aortic or mitral valve No Yes Bladder disorder No Yes Blood clot No Yes

Rheumatic fever No Yes Diabetes No Yes Lung disease No Yes

Pacemaker No Yes Thyroid disorder No Yes Bleeding disorder No Yes

Arthritis

Anesthesia problems

No Yes

No Yes

Gout No Yes Cancer

Type:

No Yes

QuickDASHINSTRUCTIONS

This questionnaire asks about your

symptoms as well as your ability to

perform certain activities.

Please answer every question, based

on your condition in the last week,

by circling the appropriate number.

If you did not have the opportunity

to perform an activity in the past

week, please make your best estimate

of which response would be the most

accurate.

It doesn’t matter which hand or arm

you use to perform the activity; please

answer based on your ability regardless

of how you perform the task.

THE

O U T C O M E M E A S U R E

Please rate your ability to do the following activities in the last week by circling the number below the appropriate response.

NO MILD MODERATE SEVERE UNABLEDIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. Open a tight or new jar. 1 2 3 4 5

2. Do heavy household chores (e.g., wash walls, floors). 1 2 3 4 5

3. Carry a shopping bag or briefcase. 1 2 3 4 5

4. Wash your back. 1 2 3 4 5

5. Use a knife to cut food. 1 2 3 4 5

6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.).

1 2 3 4 5

NOT AT ALL SLIGHTLY MODERATELY QUITE EXTREMELYA BIT

7. During the past week, to what extent has yourarm, shoulder or hand problem interfered withyour normal social activities with family, friends,neighbours or groups?

1 2 3 4 5

NOT LIMITED SLIGHTLY MODERATELY VERY UNABLEAT ALL LIMITED LIMITED LIMITED

8. During the past week, were you limited in yourwork or other regular daily activities as a resultof your arm, shoulder or hand problem?

1 2 3 4 5

NONE MILD MODERATE SEVERE EXTREME

9. Arm, shoulder or hand pain. 1 2 3 4 5

10. Tingling (pins and needles) in your arm,shoulder or hand.

1 2 3 4 5

NO MILD MODERATE SEVERESO MUCH

DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTYDIFFICULTY

THAT ICAN’T SLEEP

11. During the past week, how much difficulty haveyou had sleeping because of the pain in your arm,shoulder or hand? (circle number)

1 2 3 4 5

A QuickDASH score may not be calculated if there is greater than 1 missing item.

QuickDASH DISABILITY/SYMPTOM SCORE = (sum of n responses) - 1 x 25, where n is equal to the numberof completed responses. n

QuickDASH

Please rate the severity of the following symptomsin the last week. (circle number)

( )

SPORTS/PERFORMING ARTS MODULE (OPTIONAL)

The following questions relate to the impact of your arm, shoulder or hand problem on playing your musical instrument orsport or both. If you play more than one sport or instrument (or play both), please answer with respect to that activity which ismost important to you.

Please indicate the sport or instrument which is most important to you:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

o I do not play a sport or an instrument. (You may skip this section.)

Please circle the number that best describes your physical ability in the past week.

NO MILD MODERATE SEVERE UNABLEDIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. using your usual technique for playing your instrument or sport? 1 2 3 4 5

2. playing your musical instrument or sport because of arm, shoulder or hand pain?

1 2 3 4 5

3. playing your musical instrument or sport as well as you would like? 1 2 3 4 5

4. spending your usual amount of time practising or playing your instrument or sport? 1 2 3 4 5

WORK MODULE (OPTIONAL)

The following questions ask about the impact of your arm, shoulder or hand problem on your ability to work (includinghomemaking if that is your main work role).

Please indicate what your job/work is: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

p I do not work. (You may skip this section.)

Please circle the number that best describes your physical ability in the past week.

NO MILD MODERATE SEVERE UNABLEDIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY

1. using your usual technique for your work? 1 2 3 4 5

2. doing your usual work because of arm, shoulder or hand pain?

1 2 3 4 5

3. doing your work as well as you would like? 1 2 3 4 5

4. spending your usual amount of time doing your work? 1 2 3 4 5

SCORING THE OPTIONAL MODULES: Add up assigned values for each response; divide by4 (number of items); subtract 1; multiply by 25.An optional module score may not be calculated if there are any missing items.

QuickDASH

Did you have any difficulty:

Did you have any difficulty:

© INSTITUTE FOR WORK & HEALTH 2006. ALL RIGHTS RESERVED

THIS NOTICE DESCRIBES HOW MEDICAL

INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice, please contact our

Privacy Officer at the number listed at the end of this Notice.

Each time you visit a healthcare provider, a record of your visit

is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This Notice applies to all of the records of your care generated by your health care provider.

Our Responsibilities

Hand Surgical Associates, Inc. is required by law to maintain the privacy of your health information and to provide you with a description of our legal duties and privacy practices regarding your health information. The current Notice will be posted in the waiting room and on our website at

www.bostonhand.com. The notice will include the effective date. In addition, we will make our best effort to provide you with a copy of this notice that we request you acknowledge with your signature.

We are required by law to abide by the terms of this Notice and

notify you if we make changes to this Notice, which may be at any time. Changes to the Notice will apply to your medical information that we already maintain as well as new information received after the change occurs. If we change our Notice, it will be posted in the waiting room and on our

website at www.bostonhand.com. You may also request that a revised Notice be sent to you in the mail or you may ask for one at your next appointment or appropriate visit. This Notice will also serve to advise you as to your rights with regard to your medical information.

How We May Use and Disclose Medical Information About

You.

The following categories describe examples of the way we use and disclose medical information:

For Treatment: We may use medical information about you to provide, coordinate and manage your treatment or services. We may disclose medical information about you to other doctors, nurses, technicians, medical students, or other

personnel who are involved in your care. We may also disclose medical information to clinical laboratories and imaging facilities during the course of your care and treatment. For example, a laboratory or medical specialist

may need to know information about you to run tests or to provide treatment.

We may also provide a subsequent healthcare provider with copies of various reports that should assist him or

her in treating you. For example, your medical information may be provided to a physician to whom you have been referred so as to ensure that the physician has appropriate information regarding your previous treatment and diagnosis.

For Payment: We may use and disclose medical information about your treatment and services to bill and collect payment

from you, your insurance company or a third party payer. For example, we may need to give your insurance company information before it approves or pays for the health care services we recommend for you. The insurance company may use that information in connection with making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical

necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

For Health Care Operations: We may use or disclose, as needed, your health information in order to support our

business activities. These activities may include, but are not limited quality assessment activities, employee review activities, training of medical students, licensing, marketing, legal advice, accounting support, medical records storage and conducting or arranging for other business activities. For example, we provide medical records to a storage company for long-term safekeeping. In addition, we may also call you

by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment by telephone.

Business Associates: There are some services provided in our organization through contracts with business associates. Examples include quality accounting, legal services, billing

services, transcription services, billing/collection agencies, and record storage services. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job that we have asked them to do and bill you or your third-party payer for services rendered. To protect your health information,

however, we require the business associate to appropriately safeguard your information through a written contract.

Other Permitted and Required Uses and Disclosures That

May Be Made With Your Consent, Authorization or

Opportunity to Object

We also may use and disclose your health information as set forth below. You have the opportunity to agree or object to the use or disclosure of all or part of your health information in these instances. If you are not present or able to agree or object

to the use or disclosure of the health information (such as in an emergency situation), then your clinician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the information that is relevant to your health care will be disclosed.

Individuals Involved in Your Care or Payment for Your Care:

Unless you object, we may release medical information about you to a friend or family member who is involved in your medical care or who helps to pay for your care. In addition, we

may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Future Communications: We may communicate to you via

newsletters, mailings or other means regarding treatment options; information on health-related benefits or services, disease- management programs, wellness programs; to assess your satisfaction with our services; to remind you that you have an appointment for medical care; as part of fund raising

efforts; for population based activities relating to improving health or reducing health care costs; for conducting training programs or reviewing competence of health care professionals; or other community based initiatives or activities in which our facility is participating. If you are not interested in receiving these materials, please contact our Privacy Officer.

Other Permitted and Required Uses and Disclosures That

May Be Made Without Your Authorization or Opportunity

to Object

We may use or disclose your health information in the following situations without your authorization or without providing you with an opportunity to object. These situations

include:

As required by law. We may use and disclose health information to the following types of entities, including but not limited to:

Food and Drug Administration

Public Health or Legal Authorities charged with preventing or controlling disease, injury or disability

Correctional Institutions

Workers Compensation Agents

Organ and Tissue Donation Organizations

Military Command Authorities

Health Oversight Agencies

Funeral Directors, Coroners and Medical Directors

National Security and Intelligence Agencies

Protective Services for the President and Others

Authority that receives reports on abuse and neglect

Law Enforcement/Legal Proceedings: We may disclose health

information for law enforcement purposes as required by law or in response to a valid subpoena.

State-Specific Requirements: Many states have requirements

for reporting including population-based activities relating to improving health or reducing health care costs.

Your Health Information Rights

Although your health record is the physical property of the Hand Surgical Associates, Inc. that compiled it, you have the right to:

Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. We ask that you submit these requests in writing.

Usually, this includes medical and billing records, but does not include psychotherapy notes or information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. The

person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. Requests for access to and copies of your medical information must be submitted to HSA in writing. The cost for copies is per Board Regulations.

Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the

information by submitting a request in writing. You have the right to request an amendment for as long as we keep the information. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.

An Accounting of Disclosures: You have the right to request an accounting of our disclosures of medical information about you except for certain circumstances, including disclosures for treatment, payment, health care operations or where you

specifically authorized a disclosure. Hand Surgical Associates, Inc. will provide the first accounting to you in any 12-month period without charge. Hand Surgical Associates, Inc. will impose a fee of $10.00 each subsequent request for an accounting within the 12-month period. We ask that you submit these requests in writing.

Request Restrictions: You have the right to request a

restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is

involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure that you had. We ask that you submit these requests in writing.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Request Confidential Communications: You have the right

to request that we communicate with you about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes. We ask that you submit these requests in writing.

A Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this

notice electronically, you are still entitled to a paper copy of this notice. To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.

Complaints

If you believe your privacy rights have been violated, you may

file a complaint with us by calling (617) 738-0857 and asking for the Privacy Officer or by contacting the Secretary of the Federal Department of Health and Human Services. All complaints must also be submitted in writing. You will not be penalized for filing a complaint.

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to

use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we

provided to you.

Privacy Officer: Nina Bonazzi

Telephone Number: (617) 738-0857

Effective Date April 1, 2003

Hand Surgical

Associates, Inc.

125 Parker Hill Avenue

Boston, MA 02120

Health Insurance Portability and

Accountability Act of 1996

Privacy Policies and Procedures

Acknowledgement Receipt of Notice of Privacy Practices

By my signature below, I acknowledge receiving a copy of Hand Surgical Associates, Inc.’s Notice of

Patient Privacy Practices.

_______________________________________ ____________________________

Patient Name (Please Print) Date

_______________________________________ ____________________________

Patient Signature Date

If the patient is a minor please provide your name and relationship to the patient:

NAME: (Please print)_______________________________________________________________

RELATIONSHIP TO PATIENT:__________________________________________________________