New Intake Paperwork - Spine Doctor pins and n edl s = aching ... Mark all of the following tests...
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Page 1 New Patient Intake Form – Revised May 8, 2014 Today’s Date New Intake Paperwork Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best care possible. Please take your time and inquire at our front desk or call (602) 588 2225 if you have any questions or are unsure how to complete any section of this form. Your Name: Social Security Number: Street Address: Date of Birth: Age: City/State/Zip: Height: Weight: lbs Email: Gender: q Male q Female Physical Address Same as Mailing? q Yes q No If not, Preferred Phone: q Home q Mobile q Work Secondary Phone: q Home q Mobile q Work Email: Driver’s License # / State: Emergency Contact Name: Phone: p: Marital Status: q Married q Single q Divorced q Widowed q Other Race: q American Indian or Alaskan e q Asian or Pacific Islander q Black q White q Refuse to Report Ethnicity: q Hispanic q Non-Hispanic q Refuse to Report Primary Language: q English q Spanish q Other Were you referred to our clinic by another physician? If so, whom? Ä If not, how did you hear about us? q TV q Radio q Insurance Company q Family q Friend q PCP q www.ColoradoPain.co q Facebook q q YouTube q Other Website Pharmacy Name: Phone Number: Street Address: City/State/Zip: Payer (e.g. BC/BS): Plan: Policy/I.D. Number: Group Number: Informa n Referral Preferred Pharmacy Primary Insurance Plan Insurance policy holder: q Self qSpouse q Child q Other: Policy Holder Name: Policy Holder Gender: q Female q Male Date of Birth: Social Security Number: Complete this box if you are not the policy holder for your primary insurance
Transcript of New Intake Paperwork - Spine Doctor pins and n edl s = aching ... Mark all of the following tests...
Page 1 New Patient Intake Form – Revised May 8, 2014
Today’s Date
New Intake Paperwork
Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best care possible. Please take your time and inquire at our front desk or call (602) 588 2225 if you have any questions or are unsure how to complete any section of this form.
Your Name: Social Security Number:
Street Address: Date of Birth: Age:
City/State/Zip: Height: Weight: lbs
Email: Gender: q Male q Female
Physical Address Same as Mailing? q Yes q No If not,
Preferred Phone: q Home q Mobile q Work
Secondary Phone: q Home q Mobile q Work
Email: Driver’s License # / State:
Emergency Contact Name: Phone: p:
Marital Status: q Married q Single q Divorced q Widowed q Other
Race: q American Indian or Alaskan e q Asian or Pacific Islander q Black q White q Refuse to Report
Ethnicity: q Hispanic q Non-Hispanic q Refuse to Report Primary Language: q English q Spanish q Other
Were you referred to our clinic by another physician? If so, whom? Ä If not, how did you hear about us? q TV q Radio q Insurance Company q Family q Friend q PCP
q www.ColoradoPain.co q Facebook q q YouTube q Other Website
Pharmacy Name: Phone Number:
Street Address: City/State/Zip:
Payer (e.g. BC/BS): Plan:
Policy/I.D. Number: Group Number:
Informa n
Referral
Preferred Pharmacy
Primary Insurance Plan
Insurance policy holder: q Self qSpouse q Child q Other:
Policy Holder Name: Policy Holder Gender: q Female q Male
Date of Birth: Social Security Number:
Complete this box if you are not the policy holder for your primary insurance
Page 2 New Patient Intake Form – Revised May 8, 2014
Payer (e.g. BC/BS): Plan:
Policy/I.D. Number: Group Number:
Insurance policy holder: q Self qSpouse q Child q Other:
Policy Holder Name: Policy Holder Gender: q Female q Male
Date of Birth: Social Security Number:
Complete this sec only if your visit today is related to a Workers Compe claim
Workers Comp Company: Agent Name:
Phone number: Fax number:
Claim Number: Date of ini injury:
What number on the pain scale (0-10) best describes your pain right now?
What number on the pain scale (0-10) best describes your worst pain?
What number on the pain scale (0-10) best describes your least pain?
What number on the pain scale (0-10) best describes your average pain over the last month?
Secondary Insurance Plan (if any)
Workers Compe n Claim Inform n
Pain Loc n Pain Descr n
Complete this box if you are not the policy holder for your secondary insurance
Use the pain scale described below to rate your pain for the que below: 0 – Pain-free 1 – Very minor annoyance, occasional minor twinges 2 – Minor annoyance, occasional strong twinges 3 – Annoying enough to be distrac 4 – Can be ignored if you are really involved in your work/task, but distrac 5 – Cannot be ignored for more than 30 minutes 6 – Cannot be ignored for any length of but you can go to work and par cipate in social ac vi es 7 – Makes it difficult to concentrate, interferes with sleep, but you can func n with effort 8 – Physical ac is severely limited. You can read and talk with effort. Nausea and dizziness caused by pain. 9 – Unable to speak, crying out or moaning uncontrollably, near delirium 10 – Unconscious, pain makes you pass out
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Use this diagram to indicate the and type of your pain. Mark the drawing with the following le ers that best describe your symptoms:
Where is your worst area of pain located?
Does this pain radiate? If so, where?
Please list any areas of pain:
Approximately when did this pain begin?
What caused your current pain episode? Is your pain the result of a Motor Vehicle Accident or Personal Injury (legal term describing injury sustained to your person by negligence of another) q Yes qNo
How did your current pain episode begin? q Gradually q Suddenly
Since your pain began, how has it changed? q Decreased q Increased q Stayed the same
Check all of the following that describe of your pain: q Aching q Hot/Burning q q Stabbing/Sharp q Cramping q Numbness q Spasming q Throbbing q Dull q Shock-like q Squeezing q Tiring q Tingling/Pins and Needles
What word best describes the frequency of your pain? q Constant q Intermi nt
When is your pain at its worst? q Mornings q During the day q Evenings q Middle of the night
Onset of Symptoms
Pain Descr n
“N” = numbness “S” = stabbing “B” = burning “P” = pins and needles “A” = aching
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q Balance Problems q Bladder i ence q Bowel q Chills q Difficulty Walking q Fevers q Nausea q q Numbness/Tingling – Where? q Weakness – Where?
q I HAVE NOT RECENTLY DEVELOPED ANY OF THE ABOVE CONDITIONS.
Mark all of the following tests you have had that are related to your current pain complaints:
q MRI of the Date: Facility:
q X-ray of the Date: Facility:
q CT scan of the Date: Facility:
q EMG/NCV study of the Date: Facility:
q Other dia
q I HAVE NOT HAD ANY DIAGNOSTIC TESTS PERFORMED FOR MY CURRENT PAIN COMPLAINTS.
Mark all of the following pain treatments you have undergone prior to today’s visit:
q Chiroprac c q Physical Therapy q Spine Surgery q Psychological Therapy q Podiatrist Treatment
q Discogram – (circle all levels that apply) Cervical / Thoracic / Lumbar
q Epidural Steroid – (circle all levels that apply) Cervical / Thoracic / Lumbar
q Joint Inje – Joint(s)
q Medial Branch Blocks or Facet – (circle all levels that apply) Cervical / Thoracic / Lumbar
q Nerve Blocks – Area/Nerve(s)
q Radiofrequency Abla on – (circle all levels that apply) Cervical / Thoracic / Lumbar
q Spinal Column – (circle one) Trial Only / Permanent Implant
q Trigger Point – Where?
q Vertebroplasty / Kyphoplasty – Level(s)
q Other:
q I HAVE NOT HAD ANY PRIOR TREATMENTS FOR MY CURRENT PAIN COMPLAINTS.
Have you ever had anesthesia (seda on for a surgical procedure)? q Yes qNo
If so, have you ever had any adverse reac to anesthesia? q Yes qNo Which type of anesthesia did you react adversely to? Please check all that apply.
q Local anesthesia q Epidural q General anesthesia q IV
Do you have a family history of adverse to anesthesia? If so, to which of the following? q Local anesthesia q Epidural q General anesthesia q IV
In the past three months have you developed any new:
Tests and Imaging
Pain Treatment History
Anesthesia History
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Please indicate any surgical procedures you have had done in the past, including the date, type, and any per ent details.
Abdominal Surgery
q Gallbladder removal
q Appendectomy
q Other
Female Surgeries
q Caesarean
q Hysterectomy
q Laparoscopy
q Ovarian
q Other
Heart Surgery
q Valve replacement
q Aneurysm repair
q Stent placement
q Other
Joint Surgery
q Shoulder
q Hip
q Knee
Spine / Back Surgery
q Discectomy (levels)
q Laminectomy
q Spinal fusion (levels)
Other Common Surgeries
q Hemorrhoid surgery
q Hernia repair
q Thyroidectomy
q Tonsillectomy
q Vascular surgery
Please list any other surgeries and dates ( h an sheet if necessary) q I HAVE NEVER HAD ANY SURGICAL PROCEDURES DONE.
Please indicate which (if any) of the following blood-thinners you are taking: q Aggrenox q Coumadin q Effient q Eliquis q Lovenox q Plavix q Pletal q Pradaxa q Ticlid q Warfarin q Xarelto q Other _________________
Please list all ns you are currently taking. h an sheet, if required.
Name Dose Frequency Name Dose Frequency
Past Surgical History
Past surgical history Current
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Do you have any known drug allergies? qYes qNo
If so, please list all you are allergic to. Name Allergic Rea n Type
Topical Allergies: q Iodine q Latex q Tape Are you allergic to shellfish? q Yes q No
Mark all appropriate diagnoses as they pertain to your biological MOTHER AND FATHER only.
Arthrit
is
Cance
r
Diabete
s
Headac
hes
Heart D
iseas
e
High Blood Pres
sure
High Choleste
rol
Kidney Pr
oblems
Liver
Proble
ms
Osteoporo
sis
Rheumatoi
d Arthri
s
Seizu
res
Stroke
MotherFather
Other medical problems:
q I HAVE NO SIGNIFICANT FAMILY MEDICAL HISTORY. q I AM ADOPTED (No Medical History Available).
Are you capable of becoming pregnant? q Yes qNo If so, are you currently pregnant? q Yes qNo
Highest level of obtained: q Grammar school q High School q College q Post-graduate
Alcohol Use: q Daily Limited Use q History of Alcoholism q Current Alcoholism q Never Drinks Alcohol q Drinks Alcohol Socially
Tobacco Use: q Current Tobacco User Packs Per Day_____ How many years smoker ______ q Former Tobacco User q Has Never Used Tobacco
Illegal Drug Use: q Denies Any Illegal Drug Use q Currently Using Illegal Drugs (Which: ) q Currently Uses Marijuana q Currently Using Someone Else’s q Formerly Used Illegal Drugs (not currently using) (Which: )
Have you ever abused narco or medica ? q Yes qNo (Which: )
Allergies
Family History
Social History
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Mark the following that you have been treated for in the past:
General Medical q Cancer – Type q Diabetes – Type q HIV / AIDS
Head/Eyes/Ears/Nose/Throat q Headaches q Migraines q Head Injury q Hyperthyroidism q Hypothyroidism q Glaucoma
Cardiovascular / Hematologic q Anemia q Bleeding Disorders q Heart A ack q High Blood Pressure q High Cholesterol q Mitral Valve Prolapse q Murmur q q Poor q Stroke q Coronary Artery Disease q Pacemaker/Defibrillator
Respiratory q Asthma q
q Emphysema / COPD q Pneumonia q Tuberculosis q Valley Fever
q Bowel q GERD (Acid Reflux) q Gastrointe Bleeding q Cons pa
Musculoskeletal q q q Carpal Tunnel Syndrome q Chronic Low Back Pain q Chronic Neck Pain q Chronic Joint Pain q Fibromyalgia q Joint Injury q q Osteoporosis q Phantom Limb Pain q Rheumatoid q Tennis Elbow q Vertebral Compression
Fracture
Genitourinary/Nephrology q Bladder
q Dialysis q Kidney q Kidney Stones q Urinary
q He A / inac ve / unsure) q He B / inac ve / unsure) q He C / inac ve / unsure)
Neuropsychological q Alcohol Abuse q Alzheimer Disease q Bipolar Disorder q Depression q Epilepsy q Drug Abuse q Sclerosis q Paralysis q Peripheral Neuropathy q Schizophrenia q Seizures q Reflex Dystrophy/CRPS q Other Diagnosed ______________________
Mark the following symptoms that you currently suffer from. Note: Diagnosed condi ons/diseases should be noted under Past Medical History, above.
q Chills q Difficulty Sleeping q Easy Bruising q Excessive q Excessive Thirst q q Fevers q Insomnia q Low Sex Drive q Night Sweats q Tremors q Unexplained Weight Gain q Unexplained Weight Loss q Weakness Eyes: q Recent Visual Changes Ears/Nose/Throat/Neck: q Dental Problems q Earaches q Hearing Problems q Nosebleeds q Recurrent Sore Throats q Ringing in the Ears q Sinus Problems
Past Medical History
Review of Systems
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Cardiovascular: q Bleeding Disorder q Chest Pain q Deep Vein Thrombosis q q High Blood Pressure q Irregular Heartbeat q Lightheadedness q Shortness of Breath During Sleep q Swelling in the Feet Respiratory: q Cough q Wheezing q Pulmonary Embolism q Shortness of Breath on q Shortness of Breath at Rest
q Abdominal Cramps q Acid Reflux q Cons pa q Coffee Ground Appearance in Vomit q Dark and Tarry Stools q Diarrhea q Hernia q Musculoskeletal: q Back Pain q Joint Pain q Joint ess q Joint Swelling q Muscle Spasms q Neck Pain Genitourinary/Nephrology: q Blood in Urine q Decreased Urine Flow/Frequency/Volume q Flank Pain q Painful Neurological: q Carpal Tunnel Syndrome q Dizziness q Headaches q Numbness/Tingling q Instability When Walking q Tremors q Seizures Psychiatric: q Depressed Mood q Feeling Anxious q Stress Problems q Suicidal Thoughts q Suicidal Planning
I cer fy that the above informa on is accurate, complete and true.
I authorize Colorado Pain and any associates, assistants, and other health care providers it may deem necessary, to treat my condi . I understand that no warranty or guarantee has been made of a specific result or cure. I agree to ac vely in my care to maximize its effec veness.
I give my consent for this practice to retrieve and review my medica n history. I understand that this will become part of my medical record.
I acknowledge that I have had the opportunity to review this Practice No ce of Privacy Prac ces, which is displayed for public inspec at its facility and on its website. This No ce describes how my protected health infor n may be used and disclosed, and how I may access my health records.
I authorize to release my Protected Health (medical records) in accordance with its No ce of Privacy Prac ces. This includes, but is not limited to, release to my referring physician, primary care physician, and any physician(s) I may be referred to. I also authorize to release any informa on required in obtaining procedure authoriza n or the processing of any insurance claims.
I understand that will not release my Protected Health to any other party (including family) without my comple g a wri Authoriza for Use and Disclosure of Protected Health form, available at its facility and on its website. In the event that I am asked to provide a urine and/or blood sample, I voluntarily seek laboratory services and hereby consent to provide a urine and/or blood sample as requested. I have the right to refuse specific tests, but understand this may impact my pain management treatment. This agreement can be revoked by me at any with wr en no fica n and is valid un l revoked. I hereby assign to the Laboratory my right to the insurance benefits that may be payable to me for services provided, arising from any policy of insurance, self-insured health plan, Medicare or Medicaid in my name or in my behalf. I further authorize payment of benefits directly to the Laboratory. I understand that acceptance of insurance assignment does not relieve me from any responsibility concerning payment for laboratory services and that I am financially responsible for all charges whether or not they are covered by my insurance. I also acknowledge that the Laboratory may be an out-of-network provider with my insurer. Payment in full is expected 30 days of being of any balance due. Please note that in the event that you fail to make payment when due, this account will be referred to a collec n agency for collec ons. In that event, the fee assessed by the colle on agency will be added to the principal and interest due. You will be addi ally liable for fees. Both colle n agency fees and fees will increase the balance you owe. Signed: Date:
Medical History and Consent for Treatment
New Patient Intake Form – Revised May 8, 2014
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