Home - South Denver Spine … · Web viewHeadaches/Migraines Arthritis Neuropathy Seizures...

Zak Ibrahim, M.D.Larry Lee, M.D.

William Ballas, PA-C

Patient Registration FormPatient Information Name (Last) (First) (MI) Address Apt./Unit City, State Zip Home Cell Work Email address Date of Birth Social Security Number Male/Female

Primary Care Provider (PCP) Referring Provider

Race (circle one): American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Black/African American White Hispanic Other Decline

Primary Language (circle one): English Spanish Chinese Other:

Employment Status (circle one): Full time Part time Not Employed Self Employed Retired

Emergency Contact InformationFirst Name Last Name Contact Number Relationship to Patient

Responsible Party Information Responsible Party: Self Other (please specify): Name (Last) (First) ( MI) Date of Birth Social Security Number Male/FemaleRelationship to Patient Phone Number Address (if different from patients) City, State Zip

Primary Insurance Information (provide your insurance card to the front desk at check in) Insurance Company Subscriber ID/Policy Number Group Number Co-pay Amount

Secondary Insurance Information (provide your insurance card to the front desk at check in) Insurance Company Subscriber ID/Policy Number Group Number Co-pay Amount

I agree that the information supplied on this form is accurate and up-to-date to the best of my knowledge.



Patient Signature Date

Controlled Substance Agreement

The purpose of this Agreement is to enter a mutual contract regarding certain medicines (controlled substances) you will be taking or could be taking in the future. Prescription of controlled substances is strictly monitored by state and federal law so strict accountability is necessary.

I understand that this Agreement is based on the trust and confidence necessary in a provider/patient relationship and that my provider will manage controlled substances based on this agreement. ______ Pt. Initials

I understand that If I break this Agreement, my provider will stop prescribing these controlled substances. ______ Pt. Initials

I agree to notify my provider of any and all controlled substances or prescriptions that I receive from other providers (effective from the date of this agreement and ongoing). Such notification should occur within two (2) weeks, or sooner, if I have an encounter with my provider, following receipt of prescription. If I fail to alert my provider, I understand that I may be discharged from the practice. ______ Pt. Initials

I understand that someday my provider may recommend weaning me partially or totally from the controlled substances if he determines that, in the long run, this is likely to be in my best interest. In such situations, other medications or therapies will likely be suggested as part of my new treatment plan. I agree to respect my provider’s opinion in such circumstances and comply with the new treatment plan or discuss pursuing other treatment venues. ______ Pt. Initials

I understand that if I am suspected of diverting or distributing my controlled substances, my provider will immediately cease prescribing these medications. In this case, my provider will be required to comply with local state and/or federal reporting requirements and investigation. ______ Pt. Initials

I agree to consider following my provider’s recommendation to seek psychiatric treatment, psychotherapy, psychological treatment or referral to pain management specialist/addictionologist if my provider deems necessary. ______ Pt. Initials

If the controlled substances are prescribed to treat pain symptoms, I agree to communicate fully and honestly with my provider about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain. ______ Pt. Initials

If the medicine causes drowsiness, sedation or dizziness, I understand that I must not drive a motor vehicle or operate machinery that could put my life or someone else’s life in jeopardy. I also understand that my state may have regulations concerning driving while under the influence of drugs and accept responsibility for adhering to those regulations. ______ Pt. Initials

I understand the combination of opiates or pain medications with anti-anxiety medications such as Valium or Xanax may increase the likelihood of side effects such as stopping breathing and/or abnormal heart rhythms which may result in injury or death. ______ Pt. Initials

I understand that controlled substances which I may be prescribed have potential risks and side effects, including the risk of addiction. An over-dosage with a controlled substance may cause injury or death. Other possible complications include, but are not limited to, constipation, difficulty with urination, fatigue, drowsiness, nausea, itching, stomach cramps, loss of appetite, confusion, sweating, flushing, depressed respiration, reduced sexual function, seizures, coma, and/or aspiration. ______ Pt. Initials



I will not use any recreational mind-altering or illicit (i.e. marijuana, cocaine, methamphetamine, etc.) substances. Colorado state law allows for the legal use of marijuana. In the incident that I am using medical marijuana, I understand that certain medications may not be prescribed by my provider. I understand that I will need to avoid alcohol use since alcohol may accentuate or exacerbate side effects associated with legal controlled substances.

I will not share, sell or trade my medication with anyone nor will I take other individual’s prescribed controlled substances. ______ Pt. Initials

I will not attempt to obtain any controlled medicines, including opioid pain medicines, controlled stimulants, or anti-anxiety medications from any other provider until that provider is co-managing care with my current provider. ______ Pt. Initials

I will inform my provider of ALL current medications, including herbs, vitamins, supplements, and over-the-counter medications. I will provide an updated medication list at each visit. ______ Pt. Initials

I will not alter my medicine in any way or use any other administrative method other than what has been prescribed. Long-term agents (MS Contin, Oxycontin, etc.) must be taken whole and are not allowed to be broken, chewed, crushed, injected, and/or snorted. Potential toxicity could occur due to rapid absorption if taken inappropriately, which may lead to injury or death. ______ Pt. Initials

I understand that suddenly stopping some medications (including opioids and sedatives) can cause substantial discomfort including psychological distress, extreme achiness and fatigue, nausea, trembling, etc. ______ Pt. Initials

I understand that abruptly stopping chronic higher dose use of benzodiazepines, can cause serious risk to my health and that weaning instructions must be followed explicitly. ______ Pt. Initials

I will avoid withdrawal symptoms by budgeting my pills, not taking more medications than prescribed, and calling 2-3 days in advance for refills. I understand that “running out” of medication is not grounds for insisting on an emergency refill or urgent appointment. I understand and agree that refills of my prescriptions for controlled substances will be made only at the time of my office visit or during regular office hours. No refills will be available during evenings or on weekends. ______ Pt. Initials

I will safeguard my controlled substances from loss or theft. Lost or stolen medicines will not be replaced without a police report of the incident. ______ Pt. Initials

(FEMALES ONLY) If I plan to become pregnant or believe that I may be pregnant while taking these medications, I will immediately call my obstetric provider and prescribing provider to inform them. ______ Pt. Initials

Pharmacy InformationName of Pharmacy _____________________________________________________________________Location: _____________________________________________________________________________Phone Number: ________________________________________________________________________

If I chose to have my medications filled by a new pharmacy not listed above, I will be required to sign a new Controlled Substance Agreement at my next appointment with my updated pharmacy information. ______ Pt. Initials



I understand that changing date, quantity, or strength of medicines or altering a prescription in any way is against the law. Forged prescriptions and/or forged provider’s signatures are also against the law. If any of these instances occur, it will result in an immediate termination from this practice. ______ Pt. Initials

I authorize the provider and my pharmacy to cooperate fully with any city, state or federal law enforcement agency, including the state’s Board of Pharmacy, in the investigation if any possible misuse, sale, or other diversion of my pain medicine or other controlled substances. If requested, I authorize my provider to provide a copy of this Agreement to my pharmacy or to the requesting government agency. I agree to waive any applicable privilege or right of privacy or confidentiality with respect to these authorizations. ______ Pt. Initials

I agree that I will submit to a blood or urine test as requested by my provider to determine my compliance with my program of controlled substances. Tests may include screens for illegal substances, and my cooperation is required. Refusal of such testing may subject me to an abrupt/rapid wean schedule in order for the medication to be discontinued or prompt termination from this practice. ______ Pt. Initials

I agree that I will use my medicine at a rate no greater than prescribed and that use of my medicine at a greater rate will result in my being without medication for a period of time and possible termination of care. ______ Pt. Initials

I understand that any serious misbehavior such as yelling, threatening, cursing, etc. toward any South Denver Spine staff members will likely be cause for dismissal from the practice. ______ Pt. Initials

I agree to follow the guidelines that have been fully explained to me. All of my questions and concerns regarding treatment have been adequately answered. A copy of this document will be given to me upon my request. ______ Pt. Initials

Patient Signature __________________________________________________________________Patient Full Name (Printed) __________________________________________________________Today’s Date ______________________________________________________________________



Financial and Consent to Treatment Policies

We would like to thank you for choosing South Denver Spine for your care. We are committed to providing you with the best possible care. We want you to be informed of our office policies and require a signature to document that you have read and understand our policy. You will be given a copy for your records upon your request.

ServiceYou are here to receive a service. There are charges associated with the services we provide. Services include, but are not limited to: consultation, evaluation, and procedures. Services provided outside of our office will be charged by the entity providing the service. (i.e.: labs, MRI’s CT Scans, and DEXA Scans)Missed Appointment/Late Cancelation/No ShowOur office will call to confirm your appointment prior to the appointment date. Broken appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. To maintain our schedule, we request 24-hour notice for cancelations or rescheduling of appointments. Less than 24-hour notice will result in a $50 charge. Check InWe respect and value your time. If you are more than 15 minutes late for your appointment, we may need to reschedule. We apologize for any inconvenience this may cause you, but we do our best to run on time and by being punctual, everyone will be served in a timely and efficient manner while receiving the highest quality care. Established Patients: We request that all our established patients arrive 15 minutes prior to the scheduled appointment time for any paperwork that may be required at check in. New Patients: If it is your first visit to South Denver Spine, please arrive 30 minutes prior to your appointment time with your paperwork completed. If you were unable to complete the paperwork, we request you arrive 45 minutes early to ensure that appropriate paperwork is completed. PaymentI understand that responsibility for payment of medical services in this office for myself and/or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I understand that I am responsible for all costs of collection including attorney fees, collection fees and court costs. I understand that any unpaid balance will be assessed. Interest at the rate of 18.00% (1.5% monthly). Self-PayIf you do not have insurance, payment is required at the time of service. If special circumstances make immediate payment impossible, payment arrangements must be approved in advance by speaking to our billing manager or office manager. Once your bill is processed through our system, there may be an additional balance to us or back to you. Insurance Insurance claims are filed as a courtesy, therefore it is your responsibility to see that the claims are paid. I fully understand that I am responsible for payment of fees not covered by my insurance. Insurance referralsIt is your responsibility to understand the requirements of your insurance policy. If a referral is needed prior to seeing a specialist, you will need to obtain one through your primary care provider before an appointment can be made. If you choose to be seen without a valid referral in place, you will be responsible for any charges not covered by your insurance company.



Care and TreatmentYou have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether to undergo any suggested treatment or procedure. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). You have the right to discuss the treatment with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that should additional testing or procedures be required, additional consent forms will be created and will need to be signed for consent prior to rendering the tests or procedures.

Patient Full Name (printed) Patient Signature Date



HIPAA And Patient Communication Policy

Patient Name (printed) Date of Birth

Under HIPAA, we may discuss your protected health information, including care of financial information with individuals involved in your care. If you are not present or do not have the capacity to agree or object, in the professional judgement of the South Denver Spine physician, we conclude that the disclosure’s in your best interest. The disclosure is limited, in this circumstance, to protected health information that is directly relevant to that individual’s involvement in your care. If you would like to identify specific individuals to whom we may make the foregoing disclosures, such as if South Denver Spine is unable to reach you or in response to an inquiry, please list them below:

1) First and Last name:

Contact number: Relationship to Patient: 2) First and Last name:

Contact number: Relationship to Patient:

3) First and Last name:

Contact number: Relationship to Patient:

Communications: Please specify certain ways we may/may not communicate with you. This is to include appointment reminders, prescription refills, and financial communications.

Home/Cell Number(s) □ Yes □ NoEmail Address □ Yes □ No

I understand that the contact information provided on the Registration form will be relied upon to communicate with me regarding my medical and financial information. Should I have any changes to my contact information, I will notify South Denver Spine and complete a new Registration Form immediately.

HIPAA Acknowledgement: I acknowledge that I have been provided with South Denver Spine’s Notice of Privacy Practices or with an opportunity to obtain a copy. I have been advised of my privacy rights as provided by the Health Information Portability and Accountability Act (HIPAA) of 1996.

Patient Signature



Medical History Please choose all current and past medical conditions□ No medical condition(s) □Sleep Apnea □ Rheumatoid arthritis □ High blood pressure □ Lupus □ Bleeding disorder(s)□ Heart attack □ Parkinson’s Disease □ Anemia □ Abnormal heart rhythm □ Diabetes – Type □ Blood clots□ Lung disease/COPD □ Thyroid – Type: Hyper/Hypo □ Schizophrenia □ Tuberculosis □ Stomach ulcers □ Anxiety□ Asthma □ IBS □ Depression □ Bronchitis □ Stroke □ HIV □ Emphysema □ Seizures □ Alcoholism □ Liver Disease □ Cancer – Type □ Anorexia/bulimia □ Hepatitis – Type □ Kidney failure □ Heart murmur□ Irregular heartbeat □ Osteoporosis □ Cheat pain

* Are you under the care of another physician for ANY OTHER medical condition? □ Yes □ No If yes, please provide name and number and reason for care

Surgical History Please choose all surgeries you have had: □ None□ Spine – Neck: Level(s) Date: □ Hernia/ □ Colon/ □ Rectum□ Spine – Back: Level(s) Date: □ Hysterectomy/ □ C-section□ Brain □ Carpel Tunnel – Left/Right □ Shoulder(s) – Left/Right□ Heart □ Hip(s) – Left/Right □ Knee(s) – Left/Right□ Angioplasty/ □ Stent □ Eye(s) – Left/Right □ Throat/ □ Tonsils□ Lung □ Other: □ Gallbladder/ □ Stomach □ Appendix/ □ Intestine

Medication History Please list ALL medications including the dose. Please include over the counter medications and vitamin supplements.□ None



Allergies: □ No known drug allergies Latex Allergy: □ Yes □ No Complications with anesthesia □ Yes □ No

Medication Name and Reaction

Image History Are you claustrophobic? □ Yes □ No Have you ever worked with metal (welded)? □ Yes □ NoDo you have metal in your body? □ Yes □ No Are you/could you be pregnant? □ Yes □ NoDo you have a: □ Pacemaker □ Defibrillator □ Replacement Heart Valve □ Vena Cava Umbrella □ Implanted Pump □ Aneurysm Clip □ Neurostimulator □ Metal Plate □ Other

Social History

I live: □ Alone □ With: I live in a: □ House □ Apartment □ Assisted living □ Nursing home

Are you a cigarette smoker? □ Yes, current for year(s) □ Never □ Former, quit: If you answered yes, how much did you smoke? □ Less than ½ pack □ ½ pack □ ¾ pack □ 1 pack

□ More (How much? )

Do you drink alcoholic beverages? (Check one) □ None □ 0-3/month □ 1-2/week □ 1-2/day □ 3-5/day □ More than 5/day

Have you ever had a problem with dependence? □ Yes □ No

If yes, what was the dependence and for how long?

Are their law suits pending or contemplated related to this condition? □ Yes □ No If yes, please provide the attorney’s name and contact number:



Please write any additional information that you feel is important for us to know.

Family Medical History

Mother Father Brother SisterHigh Blood Pressure

Heart Disease

Diabetes

Cancer (Type)

Stroke

Headaches/Migraines

Arthritis

Neuropathy

Seizures

Parkinson’s Disease

Alzheimer’s/Dementia

Multiple Sclerosis

Please list other significant medical family history:



Patient Name (Print) Date

Back Only

Patient Name (print): Date:

Reason for Today’s Visit:

Symptoms: □ Back pain □ Leg pain □ Neck pain □ Arm pain □ Numbness □ Weakness □ Scoliosis

□ Other:

How long have you had your symptoms?

What caused your symptoms? □ Unknown □ Injury □ Other:

What % of your symptoms are in the BACK and LEG? (please check one box)□ Back 0%, Leg 100%□ Back 10%, Leg 90%□ Back 25%, Leg 75%□ Back 50%, Leg 50%□ Back 75%, Leg 25%□ Back 90%, Leg 10%□ Back 100%, Leg 0%

What % of your symptoms are in each LEG? (please check one box)□ No LEG symptoms□ Right 0%, Left 100%□ Right 10%, Leg 90%□ Right 25%, Left 75%□ Right 50%, Left 50%□ Right 75%, Left 25%□ Right 90%, Left 10%□ Right 100%, Left 0%

Where in your LEG do you have PAIN or TINGLING?Right Left□ None □ None□ Buttock □ Buttock□ Thigh, back □ Thigh, back□ Thigh, front □ Thigh, front□ Calf □ Calf

Where in your LEG do you have NUMBNESS?Right Left□ None □ None□ Buttock □ Buttock□ Thigh □ Thigh□ Ankle □ Ankle□ Calf □ Calf

Where in your LEG do you have WEAKNESS?Right Left□ None □ None□ Buttock □ Buttock□ Thigh □ Thigh□ Ankle □ Ankle□ Calf □ Calf



□ Foot □ Foot □ Foot/toes □ Foot/toes □ Foot □ Foot

Neck Only


Reason for Today’s Visit:

Symptoms: □ Back pain □ Leg pain □ Neck pain □ Arm pain □ Numbness □ Weakness □ Scoliosis

□ Other:

How long have you had your symptoms?

What caused your symptoms? □ Unknown □ Injury □ Other:

What % of your symptoms are in the NECK and ARM? (please check one box)□ Neck 0%, Arm 100%□ Neck 10%, Arm 90%□ Neck 25%, Arm 75%□ Neck 50%, Arm 50%□ Neck 75%, Arm 25%□ Neck 90%, Arm 10%□ Neck 100%, Arm 0%

What % of your symptoms are in each ARM? (please check one box)□ No ARM symptoms□ Right 0%, Left 100%□ Right 10%, Left 90%□ Right 25%, Left 75%□ Right 50%, Left 50%□ Right 75%, Left 25%□ Right 90%, Left 10%□ Right 100%, Left 0%

Where in your ARM do you have PAIN or TINGLING?Right Left□ None □ None□ Upper Back □ Upper Back

Where in your ARM do you have NUMBNESS?Right Left□ None □ None□ Upper arm □ Upper arm

Where in your ARM do you have WEAKNESS?Right Left□ None □ None□ Shoulder □ Shoulder



□ Shoulder □ Shoulder□ Upper arm □ Upper arm□ Forearm □ Forearm□ Hand □ Hand

□ Forearm □ Forearm□ Thumb □ Thumb□ Index finger □ Index finger□ Ring/small □ Ring/small

□ Arm □ Arm□ Forearm □ Forearm□ Hands □ Hands

BACK PAIN

LEG PAIN

NECK PAIN

ARM PAIN

Please mark the areas on the diagram below where you are having symptoms. Please use the following symbols to mark the diagram:

Pain; -------Pins and Needles; 0000000



Numbness; xxxxxxx

Back (answer if applicable):

How does the pain travel? □ Stays in my back □ Starts in my back and goes down my legThe worst position for pain is: □ Sitting □ Standing □ Walking □ I have no painBending forward? □ Increases the pain □ Decreases the pain □ No effectLying down? □ Increases the pain □ Decreases the pain □ No effectHow many minutes can you STAND without pain? □ 0-10 □ 15-30 □ 30-60 □ 60+How many minutes can you WALK without pain? □ 0-10 □ 15-30 □ 30-60 □ 60+

Neck (answer if applicable):

How does the pain travel? □ Stays in my neck □ Starts in my neck and goes down my armRaising my arm: □ Increases the pain □ Decreases the pain □ No effectMoving my neck: □ Increases the pain □ Decreases the pain □ No effect Do your hands feel clumsy? □ Yes □ No

Do you have a problem with balance or tripping? □ Yes □ NoDo you have headaches in the back of your head? □ Yes □ NoDoes coughing or sneezing increase your symptoms? □ Yes □ NoDo you have difficulty with bladder/bowel control? □ Yes □ No If yes, for how long? Have you missed work because of your symptoms? □ Yes □ No If yes, how much time?

Previous treatments for my condition have included: (check all boxes that apply)□ Nothing (no medications, therapy, manipulations, injection, etc…)□ Physical Therapy – Did it help relieve your symptoms? □ Yes □ No□ Chiropractic manipulation – Did it help relieve your symptoms? □ Yes □ No□ Brace – Did it help relieve your symptoms? □ Yes □ No□ Spinal Injections – How many injections have you had?



Did the injection(s) relieve your pain? □ Yes □ No If yes, for how long?

□ Surgery – How many surgeries have you had on your back? Neck? Did the surgery relieve your symptoms? □ Yes □ No If yes, for how long?

□ Medications – Did it help relieve your symptoms? □ Yes □ No□ Acupuncture – Did it help relieve your symptoms? □ Yes □ No If yes, for how long? □ Massage therapy – Did it help relieve your symptoms? □ Yes □ No□ Other treatment(s):

Previous doctors seen for your spine problem: □ NoneDoctor Specialty Facility Name and Number Recommendations/Treatments

Review of Body Systems

Yes No Yes NoGeneral Stomach and Digestion

Fever Nausea Fatigue VomitingUnexplained weight loss Blood in VomitUnexplained weight gain Blood in Stools

ENT JaundiceGlaucoma UlcerCataracts Gastritis Hearing loss GERDBalance problems Colon DiseaseDizziness Constipation Sinus problems Urinary Diarrhea Bladder Infection(s) Other: Blood in UrineChest pain Urinary FrequencyHigh cholesterol Urinary Urgency Swelling of Feet IncontinenceSwelling of Ankles Prostate diseaseOther: Kidney Disease

Lungs Kidney StonesShortness of Breath Other:



Bloody Sputum Nervous/Muscular SystemsPneumonia – Recent/Past (circle) Low Back PainOxygen use Neck painOther: Leg pain/weakness/numbness (circle)

Psychological Arm pain/weakness/numbness (circle)Depression Hand pain/weakness/numbness (circle)Anxiety Frequent Headaches/Migraines (circle)Bipolar Memory Loss/Confusion (circle)Panic Attacks Difficulty SpeakingOther: Double/Blurred Vision (circle)

Multiple SclerosisBurning/Tingling (circle)Nagging/Sharp/Throbbing (circle)Other:


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