Patient Agreement for Outpatient Services

In order to provide the best quality of care, it is critical for you to be compliant with your treatment program. You will be asked to sign an exact copy of this document upon your first visit. By signing below, I understand I agree to the following: 1. I will comply with the orders and/or recommendations of my treatment team. 2. I will receive two separate charges billed to my insurance company for every office visit and procedure. (a facility charge and a provider charge). 3. In the event I am a self-pay patient, I am expected to pay in full at the time of the appointment, unless other arrangements have been made with Shepherd Center Financial Services prior to my visit. 4. I am required to schedule an appointment to be seen by a provider at the Shepherd Center. I cannot be seen as an emergency walk in appointment. 5. I am required to arrive 30 minutes prior to my appointment time. If I am late for physician appointments, I will be rescheduled for another day. Walk-ins will not be accepted. 6. I am required to give 48 hours notice for cancellations/rescheduling by calling (404) 352-2020. Cancellation and no show for your scheduled appointment is considered a serious event and negatively effects your treatment plan. Your provider has the right to terminate services based on your attendance record for your appointment. 7. All patients receiving a procedure must have a driver (not bus or taxi). 8. It is my responsibility to inform the Shepherd Center of any changes in my insurer, address, and telephone number. 9. If I am a worker’s compensation patient, it is my responsibility to inform the Shepherd Center staff of any changes in my insurer, adjustor, or case manager, or if my claim is settled. 10. Any request for completion of disability papers should be directed to my primary Shepherd Center treating physician and that the Shepherd Pain Institute does not complete disability papers. 11. Threatening, intimidating, hostile, sexual explicit, violent and/or verbally abusive behavior will not be tolerated. 12. No illegally controlled substances/recreational drugs may be used during my treatment at the Shepherd Center. I agree to have random drug and alcohol screens upon request by my provider. If any screen is found to be positive, I agree to address this issue through the recommendation of my treatment team. 13. Shepherd Center is a smoke-free facility and I agree not to smoke in the facility. 14. Possession of weapons and destroying or stealing Institute property will result in immediate discharge from all Shepherd Center programs. 15. Seven business days notice is necessary for medication refills Failure to comply with one or more of the above statements may result in discharge from all Shepherd Center Programs for three years upon the recommendation from your treatment team after a review of your behavior at Shepherd Center. Thank you for choosing the Shepherd Center. _______________________________________________________________________________________ Patient Date _______________________________________________________________________________________ Shepherd Center Staff Title Date OP-571 07/10 revised 

Patient Name : _____________________________________

Account #: ________________________________________

MR # : ____________________________________________

Date : ____________________________________________

SPI 8/07

WHO REFERRED YOU?

WHO IS YOUR PRIMARY CARE PHYSICIAN?

PAIN HISTORYWHAT IS YOUR PAIN COMPLAINT/REASON FOR VISIT?

WHEN DID YOUR PAIN BEGIN?

WAS THERE AN INJURY? ❏ YES ❏ NO (IF YES, PLEASE EXPLAIN)

IS YOUR PAIN THE RESULT OF AN ACCIDENT? ❏ YES ❏ NO (IF YES, PLEASE DESCRIBE)

WHAT RELIEVES YOUR PAIN?

WHAT MAKES YOUR PAIN WORSE?

PREVIOUS TREATMENT FOR PAIN PLEASE CIRCLE ONE HELPFUL?ONSEYONSEYSKCOLB EVRENONSEYONSEYSLARUDIPEONSEYONSEYYREGRUSONSEYONSEYSNOITACIDEMONSEYONSEYTINU SNETONSEYONSEYYPAREHT LACISYHPONSEYONSEYKCABDEEFOIBONSEYONSEYSISONPYHONSEYONSEYGNILESNUOCONSEYONSEYROTCARPORIHCONSEYONSEYERUTCNUPUCA

PATIENTINTAKEFORM

SURGICAL HISTORYLIST ANY SURGERIES YOU HAVE HAD

:ETADYREGRUS FO EPYT

MEDICAL HISTORYLIST ANY MEDICAL CONDITIONS YOU HAVE BEEN DIAGNOSED WITH(DIABETES, HIGH BLOOD PRESSURE, HEART ATTACK, THYROID PROBLEMS ETC):

2020 Peachtree Road NWAtlanta, GA 30309

SOCIAL HISTORYMARITAL STATUS: ❏ MARRIED ❏ SINGLE ❏ WIDOWED ❏ DIVORCEDCHILDREN?:

WHO LIVES WITH YOU?

DO YOU SMOKE? ❏ NO ❏ YES IF YES, HOW MUCH?

DO YOU DRINK ALCOHOLIC BEVERAGES: ❏ NO ❏ YES IF YES HOW MUCH?

ARE YOU PREGNANT OR PLAN TO BECOME PREGNANT? ❏ YES ❏ NO

HIGHEST EDUCATION LEVEL COMPLETED:

OCCUPATION: NAME OF EMPLOYER:

DO YOU HAVE ANY HISTORY OF ADDICTION TO ANY SUBSTANCE? ❏ NO ❏ YES (IF YES, DESCRIBE)

FAMILY HISTORYDO ANY DISEASES RUN IN YOUR FAMILY? PLEASE LIST BELOW:

ALLERGIESARE YOU ALLERGIC TO LATEX PRODUCTS? ❏ YES ❏ NOARE YOU ALLERGIC TO ANY MEDICATIONS? ❏ YES ❏ NO IF YES, WHICH ONES?

MEDICATIONSWHAT MEDICATIONS, IF ANY, ARE YOU TAKING NOW?(PLEASE LIST ALL MEDICATIONS BOTH PRESCRIPTION AND OVER THE COUNTER)

DIAGNOSTIC STUDIESPLEASE LIST THE APPROXIMATE DATE OF TEST, THE NAME OF THE FACILITY WHERE THE TESTWAS PERFORMED, THE NAME OF THE ORDERING PHYSICIAN AND THE RESULTS, IF KNOWN.TEST DATE FACILITY PHYSICIAN RESULTS

X-RAY

CT SCAN

MRI

EMGSPI 08/07

?NETFO WOHHTGNERTS/ESODENICIDEM

2020 Peachtree Road NWAtlanta, GA 30309

Patient Name : _____________________________________

Account #: ________________________________________

MR # : ____________________________________________

Date : ____________________________________________

HEAD Headaches Trouble with hearing Trouble with eyesight Nasal discharge Hay Fever, frequent sneezing Sinus trouble, post nasal drip

THROAT Hoarseness Ulcer of tongue or mouth Trouble with gums or teeth Sore throat

LUNGS Asthma, wheezing Cough Cough up blood Tuberculosis Shortness of breath

CARDIOVASCULAR High blood pressure Chest pain Irregular beat or palpitation of heart Awaken at night with shortness of breath

BLADDER AND KIDNEY Frequency urgency or pain with urination Passed blood or kidney stone Trouble starting or stopping of urinary stream

STOMACH AND BOWELS Trouble swallowing Abdominal pain, nausea, vomiting Acid Reflux (“Heartburn”) Stomach ulcer/Duodenal ulcer Black bowel movements Diarrhea Constipation Hemorrhoids or rectal itching

REVIEW OF SYSTEMSPlease check any symptoms below that you currently have:

ENDOCRINE Increased thirst, hunger Sudden weight change Sensitive to heat/cold Change in skin, body hair Change in sex drive

SKIN Rash Tumor on skin

MUSCULAR Low back pain Joint pain Arthritis Neck pain

NERVOUS Backache Balance prolems Numbness or tingling anywhere Weakness Trouble walking

MISCELLANEOUS Problems with sleep Dizziness Depression Fatigue Anemia or difficulty with bleeding Sexual problems

OTHER? (Please describe)

PROBLEM LISTPlease check any of the following below that you have had or currently have a problem with:

Alcohol

Acquired Brain Injury

ALS

Asthma

Bladder Pain / Spasms

Blood Clots

Blood in Stool

Blood in Urine

Cerebral Palsy

Cigarettes

Current Pregnancy

Diabetes

Drugs

Dysreflexia

Frequent UTI

Gynecological Problems

Hay Fever / Allergies

High Blood Pressure

HIV (or AIDS)

Impaction

Kidney Failure

Multiple Sclerosis

Neurogenic Bladder

Neurogenic Bowel

Paraplegia

Pneumonia

Post Polio

Psychiatric Problems

Respiratory Failure

Quadriplegia / Tetraplegia

Seizures

Skin Problem

Spina Bifida

Spinal Problems

Stroke

Ventilator Use

SPI 08/07

2020 Peachtree Road NWAtlanta, GA 30309

1. Have you ever undergone sedation before?

2. Have you/family member had major problems (severe nausea, high fever, breathing difficulty) with surgery or anethesia?

3. Diabetes on pills on insulin

4. High Blood Pressure on medicine

5. Cardiovascular Disease Angina/Chest pain Heart Failure Heart Attack

Irregular heart beat/Pacer/AICD Prior heart surgery/angioplasty

Valve disease/murmur(including Mitral valve Prolapse)

6. Activity Level Limited Climb 1 or more flight of stairs Regular exercise

7. Lung Disease Emphysema Shortness of breath Asthma/wheezing

Sleep Apnea CPAP: Yes No

8. Neuromuscular Disease Muscle Weakness Paralysis Seizures Rheumatoid Arthritis

Stroke/TIA

9. Kidney Disease On dialysis

10. Liver Disease Hepatitis/jaundice

11. History of Abnormal Bleeding Blood transfusion

12. Have you donated blood for this procedure?

13. Hiatal Hernia Acid reflux

14. Back problems or chronic headaches

15. Have you had a cold, “flu” or fever within the past week?

16. Do you smoke or have you in the past? Packs per day: _____ Yrs. Smoking: ____ Quit when: __________

17. Do you drink alcohol? Drinks/beers per day: _______

18. Have you taken oral or IV steroids within the past 6 months?

19. Do you take any of the following medications? Glucophage, Glucovance, Aspirin, Coumadin, Herbal medicines

20. Do you have any loose teeth, caps, bridges, dentures or other dental work?

NOTE: Dental injury is a risk despite every precaution

21. Could you be pregnant? Date of last menstrual period: ________________________

22. Do you have a history of pregnancy related complications?

If pregnant, have you experienced any difficulties? Yes No

23. Do you have any other medical problems not listed above? Describe:______________________________________

24. Are you taking blood thinners?

25. Do you have an allergy to contrast dye?

ALLERGIES - please decribe any drug/latex allergies: _____________________________________________________

List all medication you are taking (including “over the counter”) _____________________________________________________

______________________________________________________________________________________________________

MATERIAL RISKS: Georgia law requires that material risks be disclosed to you. These include but are not limited to: infection, allergic

reaction, scarring, blood loss requiring transfusion with associated risk of AIDS and/or hepatitis, loss of function of any limb or

organ, paralysis, brain damage, cardiac arrest or death. OTHER RISKS: Anesthetic procedures may also result in lung injury,

headaches, backache, or trauma to adjacent structures. By signing below, you acknowledge that these risks have been disclosed

to you.

YES NO

Do you now have or have you ever had:

Patient Name

Medical Record Number

Please fill out this form by checking the appropriate boxes and sign where indicated.

Date

Signature of person completing form: ____________________________________________________________

SPI 08/07

2020 Peachtree Road NWAtlanta, GA 30309

Patient Name : _____________________________________

Account #: ________________________________________

MR # : ____________________________________________

Date : ____________________________________________

Please indicate where you are experiencing pain on the drawing below

Rate Your Current Back Pain on the Scale Below

PAIN DIAGRAM

UNBEARABLE PAINNO PAIN

0 1 2 3 4 5 6 7 8 9 10

SPI 8/07

2020 Peachtree Road NWAtlanta, GA 30309

ADOLESCENT PROGRAM

Experience counts. Studies show that patients are morelikely to experience fewer medical complications,

achieve more functional independence and return to schooland community if they go to a hospital that treats a high volume of catastrophically injured patients.

TREATMENT

Hundreds of teen patients are leading longer and betterquality lives because of the acute care, rehabilitation andmedical and surgical care available at Shepherd Center. Ouradolescent track begins in the intensive care unit and focus-es on a healthy lifestyle and the highest level of functioningand independence possible. It includes:

• An interdisciplinary approach to addressing the teenpatient’s special need for independence, socialization,age-appropriate activities, security and privacy.

• A physician-led, 10-member, dedicated treatment team.

• A high priority on the involvement of family and friends.

• Private rooms to allow patients to spend the night,when possible.

• Education and training in problem solving, stigma man-agement, self-advocacy, drug and alcohol awareness, self-care and sexuality.

• Care coordinated by a case manager who provides utilization review.

EDUCATION

Staying on track academically is extremely important for catastrophically injured teens. More than 90 percent of ourspinal cord injured adolescent patients return to school within two weeks of discharge. Of those, 95 percent graduate on time with their class with their pre-injury GPA.

Driving evaluations, augmentative communicationassessments, and vocational assessments are another part ofShepherd’s whole-patient approach to education.

RETURN TO SCHOOL PROGRAM

Recognizing that adolescents rely on school experiencesand positive peer interactions for much of their self-esteemand growth, Shepherd Center has developed a program to facilitate the back-to-school transition. Designed by the individual patient, the program can include in-schoolawareness and sensitivity training for school staff and stu-dents, as well as instruction in medical issues that may ariseduring the school day.

Shepherd Center treats more than

60 inpatient teenagers with

catastrophic injuries each year

fact sheet2020 Peachtree Rd. N.W. Atlanta, GA 30309 404-352-2020 shepherd.org

Because all of our resources are devoted to treating central nervous system injuries and illnesses, Shepherd Center has more experience treating teenagers with these kinds of catastrophic brain and spinal cord injuries than general rehabilitation facilities. This experience – approximately 60 youngsters age 12 to 17 each year – is reflected in our outcomes, which exceed national averages.

For adolescents with a brain injury, 95 percent return to school within three to six months.

MKT 12/11

Directions to shepherD center

From south oF AtlAntATake I-75 North or I-85 North through downtown Atlanta via the I-75/85 Connector. • Bear right at the “Y” onto “I-75 North – Marietta/Chattanooga.” • Take first exit #252A “Northside Drive (Hwy. 41).” • Turn right onto Northside Dr. and continue for 1/2 mile. • Turn right at the first light onto Collier Rd.; follow to dead-end. • Turn left onto Peachtree Rd.; stay in left lane. • Turn left at second light into Shepherd Center.

From northwest oF AtlAntATake I-75 South to exit #252 “Howell Mill Road/Northside Drive.” • On exit ramp, follow signs to Howell Mill Rd. • Turn left onto Howell Mill Rd. • At second traffic light, turn right onto Collier Rd.; follow to dead-end. • Turn left onto Peachtree Rd.; stay in left lane. • Turn left at second light into Shepherd Center.

From northeAst oF AtlAntATake I-85 South to exit #86 “Hwy.13 South/ Peachtree St.” • Follow ramp for approx. three miles. • Pass the exit ramp for I- 75/I-85 South. • Bear right onto next exit ramp for “U.S. 19/ N.Peachtree St./Buckhead.” • Turn right onto Peachtree St.; go approx. one mile. • Turn left at seventh traffic light into Shepherd Center.

From north oF AtlAntATake GA. 400 South to exit #2 “Lenox Rd./Buckhead” • Turn right at end of ramp. • At second traffic light, turnleft onto Piedmont Rd. south • Merge into right lane. • At second traffic light, turn right onto Peachtree Rd.; continue for three miles. • Turn right into Shepherd Center.

From public trAnsportAtion (mArtA)From Arts Center Station, N5, take bus #110, which travels north on Peachtree St. • About 1.5 miles north ofthe Arts Center Station, exit the bus at traffic light beside the digital “Atlanta Population Now” sign. You will be directly across the street from Shepherd Center.

pArking inFormAtionFollow the Shepherd Center driveway to park in the deck marked “Shepherd Parking.” • From any level, take the elevator to first floor. • Proceed across bridge to the security desk for assistance to your location. • Please do not walk along the driveway.

Shepherd Center is located at 2020 Peachtree Rd., N.W., next to Piedmont Hospital

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FOR DIRECTIONS BY PHONE: 404-350-7600FOR GENERAL INFORMATION

Call our main number at 404-352-2020 orvisit our website at: www.shepherd.org