Consultants in Pain Medicine, P.A. Phone (210) Fax (210)
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1 Consultants in Pain Medicine, P.A. Phone (210) Fax (210) Scott P. Worrich, M.D. Medical Center Legacy Oaks Santa Rosa Westover Hills Medical Plaza II 5368 Fredericksburg Rd State Hwy. 151 Building C, Suite 210 Suite 120 San Antonio, TX San Antonio, TX Boerne Location 113 Falls Court Building C, Suite 400 Boerne, TX 78006
2 Legacy Oaks Boerne 5368 Fredericksburg Rd 113 Falls Court Bldg. C., Suite 210 Bldg. C., Suite 400 San Antonio, TX Boerne, TX Westover Hills Westover Hills Medical Plaza II State Hwy. 151 Suite 120 San Antonio, TX 78251
3 Consultants in Pain Medicine, P.A Fredericksburg Rd. Ste. 210 San Antonio, Texas Phone (210) Fax (210) DATE: Dear Mr./Mrs./Ms., You have been referred to Scott P. Worrich M.D., with Consultants in Pain Medicine by your physician. Please complete the enclosed information regarding your pain on the patient intake form provided for you. You must bring the questionnaire completed to the office on, at a.m./p.m. at our location. (arrival time) (see map attached) ATTACHED WITH THE PACKET YOU MUST HAND CARRY ANY MRIs, X-RAY OR CT FILMS ALSO ANY IMAGAING REPORTS (LESS THEN 5 YRS. OLD). **NOTE IF REFERRED BY MILITARY BASE DOCTORS MAKE SURE YOU HAVE THE IMAGING REPORTS AT THE TIME OF YOUR APPOINTMENT, ** IF THE FORMS ARE NOT COMPLETELY FILLED OUT YOUR APPOINMENT MAY BE RESCHEDULED OR DELAYED. Please be aware that you are liable for any applicable co-pays at office and facility visits. Please follow up with your insurance company to be prepared for the cost that may possibly be incurred. Please bring your insurance card to your appointment. If you do not understand the questions and require assistance arrive 30/45 minutes prior to your office appointment and please call our office. * If you are scheduled for an injection at the surgery center please arrive at least 1 hour prior to your procedure. You must bring a driver. You should not eat or drink for 6-8 hours prior to your procedure except for essential medications, which can be taken with a sip of water only. *Please notify our office if you are taking any Blood Thinners so we can arrange your lab work to be done prior to your procedure. Also, if you are on a blood thinner for cardiac reasons, especially an artificial heart valve, you must discuss stopping it with your primary care physician or cardiologist first. If you are placed on Lovenox, it must be stopped 12 hours prior to your procedure. We appreciate your cooperation and if you have any questions or require further assistance, please feel free to contact our office. Thank you, Cheryn, Scheduler
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5 Consultants in Pain Medicine, P.A. ASSIGNMENT OF BENEFITS Private insurance authorization for assignment of benefits and information release: I, the undersigned, authorize payment of medical benefits to Consultants in Pain Medicine for any services furnished to me by the physician. I understand I am financially responsible for any amount not covered by my insurance policy. I also authorize Consultants in Pain Medicine to release to my insurance company, referring physician and other consultants on my case information concerning health care, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits. Date Signed MEDICARE LIFETIME SIGNATURE ON FILE I request that payment of authorized Medicare benefits be made on my behalf to Consultants in Pain Medicine for any services furnished to me by the physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. Date Signed CERTIFICATION Consultants in Pain Medicine, P.A. is pleased to offer you treatment for your injury or suffering. However, you are advised that according to most commercial insurance policies and generally accepted practice, treatment for work related chronic injuries must first be filed under Texas Workman s Compensation. We will be happy to assist you in this process. Also, if this is a litigation case, our office needs to be informed before services are rendered. I hereby certify that I am /am not seeking treatment for an illness or injury that resulted from an incident/accident at my place of work or from a motor vehicle accident. MVA / Date of Incident If applicable, Attorney s Name Phone # Print Patient Name Patient Signature Date Health Insurance Portability and Accountability Act By signing this document, I acknowledge that I have been given the opportunity to read the Notice of Privacy Practices of Consultants in Pain Medicine, P.A. Print Patient Name Patient Signature Date
6 Consultants in Pain Medicine, P.A Fredericksburg Rd. Ste. 210 San Antonio, Texas Phone (210) Fax (210) I hereby authorize Consultants in Pain Medicine, Inc., to take my photograph for inclusion in my medical chart retained by the clinic. I understand this photograph is solely for the purpose of identification and familiarization by the office staff and the clinic physician(s). Patient Signature Please fill out and sign the following release form so we can obtain copies of any medical records that may be needed in order to assess your condition more thoroughly. Date: I, hereby authorize the release of my medical records to Consultants in Pain Medicine. Patient Signature Date Witness: Date
7 Information Form DATE: Name: Date of Birth: Age: Employer: Occupation: Do you work now? Yes No Part Time What does your work involve? Name of Doctor who referred you? List of other Doctors you have seen for this pain problem Names of other Doctors you see for other medical reasons: How long have you had your pain? Give details of injury or circumstances causing your pain: Were you injured on the job? Yes No Is there an attorney involved? Yes No How and when were you treated for this problem? Have you had surgery for this problem? Yes No If yes, give: Date Hospital Name of surgeon Tests performed: X-Rays MRI CT Scan EMG Bone Scan Discogram Other Tests Where & When: What is your pain status now? Worse Better Same Has it changed? How? What other treatments have you received? (i.e., bed rest, physical, therapy, hypnosis, chiropractic manipulation, acupuncture, injections) Please list details: Treatment: Where: When:
8 MEDICATIONS Please list medications to which you are ALLERGIC, and the type of reaction to each (i.e. rash, upset stomach, etc..): Please list medications you have previously taken for pain: MEDICATION HELPFUL? REASON FOR STOPPING USE Please list medications you are CURRENTLY TAKING FOR PAIN: MEDICATION DOSAGE TIMES/DAY HELPFUL? DOCTOR Please list other medications you are CURRENTLY TAKING (include vitamins, etc.): MEDICATION HELPFUL? DOCTOR
9 For the following descriptions, place a SINGLE number for each word that describes you pain: NONE = 0 MILD = 1 MODERATE = 2 SEVERE = 3 STANDING STOOPING WALKING CLIMBING SITTING LAYING DRIVING STRESS LIFTING ANGER TWISTING INTERCOURSE BENDING PUSHING Married? Yes No How many children do you have? Level of Education? What type of work do you do? Have you lost or gained weight in the last six months? Yes No How many pounds? Lost lbs. Gained lbs. Do you: Drink alcoholic beverages? Yes (Amt) No Smoke? Yes (Amt) No Have you ever been treated for addiction to alcohol or any other substance? Yes No Do you currently take any illegal drugs or have you taken any narcotics in a non-prescribed manner? Y/N FAMILY HISTORY (Circle all that apply TO YOUR BLOOD RELATIVES) Asthma Genetic Disorders (specify) Kidney Problems (specify) Arthritis Headaches Lung Problems (specify) Cancer (specify) Heart Problems (specify) Seizures Diabetes High Blood Pressure Tuberculosis Other: Anxiety Please circle any of the following that APPLY TO YOU Constipation GI Bleed Heart Problems (specify) Kidney Problems (specify) Arthritis Depression Glaucoma HIV Lung Problems (specify) Asthma Diabetes Hepatitis High Blood Pressure Stomach Ulcer Cancer (specify) Genetic Disorder (specify) Headaches Impotence Seizures Tuberculosis Blood Thinner Other: Please list previous surgeries: DATE PROCEDURE SURGEON HOSPITAL
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DATE: Dear Mr./Mrs./Ms., location.
Consultants in Pain Medicine, P.A. 5368 Fredericksburg Road Legacy Oaks Building C Ste. 210 San Antonio, Texas 78229 Phone (210) 546-1470 Fax (210) 546-1479 DATE: Dear Mr./Mrs./Ms., You have been referred
Consultants in Pain Medicine, P.A. Phone (210) Fax (210) Scott P. Worrich, M.D. Donald Stevenson, PA-C
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SECONDARY INSURANCE PRIMARY INSURANCE CORNERSTONE PAIN MANAGEMENT PATIENT INFORMATION First Name: Dr. Mr. Mrs. Ms. Miss MI: Last Name: Social Security: Age: Date of Birth: Gender: Address: City: State:
Please do not hesitate to reach out to our team with any questions regarding your New Patient appointment. We look forward to meeting you soon.
We are excited about your upcoming appointment with Texas Alzheimer s & Memory Disorders. Please find the enclosed ew Patient packet that we are requesting be completed prior to your visit with us. Appointment
PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage
BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage Patient Name Date Address City State Zip Phone (home) (cell) Emergency Contact Name Phone Employer Date of Birth Work Phone Social Security # Is condition
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
Chiropractic Case History/Patient Information
Chiropractic Case History/Patient Information 1 Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: E-mail address: Fax # Cell Phone: Age: Birth Date: Race: Marital:
CHIROPRACTIC EXPERIENCE ABOUT YOU REASON FOR THIS VISIT HEALTH HABITS MEDICATIONS YOU TAKE SUPPLEMENTS YOU TAKE
ABOUT YOU CHIROPRACTIC EXPERIENCE NAME: ADDRESS: CITY: HOME PHONE: EMAIL ADDRESS: STATE/ZIP CODE: CELL PHONE: WHO REFERRED YOU TO OUR OFFICE? HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF ( ALL THAT
PERSONAL INFORMATION. First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip:
ADULT INTAKE FORM Date: PERSONAL INFORMATION First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip: Cell Phone: ( ) Alternate Phone: ( Text Reminders: Y N Before
PATIENTS DEMOGRAPHICS
PATIENTS DEMOGRAPHICS Date: First Name MI Last Name Sex: M or F (Circle one) Age: Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell/Pager No: Date of Birth: Single: Married: Social Security
CALIFORNIA PAIN MEDICINE CENTERS New Patient History and Intake Form
CALIFORNIA PAIN MEDICINE CENTERS New Patient History and Intake Form Date: Name: _ Age: Sex: Occupation: 1. Who referred you? 2. What is your primary complaint? PCP: Referring Specialist: How long have
WOODLANDS FAMILY CHIROPRACTIC
We appreciate you choosing our office. Is there anyone we can thank for referring you? Please indicate the main reason you are seeing us today: IF you are seeing us for a PAIN related issue, USE THE SYMBOLS
Practice Member Profile
Practice Member Profile Please print Name: : Phone number: (H) (C) Cell provider: Address: City: State: Zip: of Birth: Age: Male Female (circle one) Marital Status: Name of Spouse: Number of Children:
New Practice Member Paperwork
Cornerstone Family Chiropractic Health Information Form 928.237.9477 www.cfc4familyhealth.com 2225 E State Route 69 Suite A Prescott, AZ 86301 New Practice Member Paperwork This form is for adults only.
Date. Patient General Information
Date John D. Belde, DC Jonas T. Johnson, DC Kelley McGowan, PT 211 Hwy 25, P.O. Box 717 Monticello, MN 55362 763.295.4105 Patient General Information Name Date of Birth Gender Address Social Security No.
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. Thank you for your cooperation. Patient
Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team
Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone
Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C
Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite 402 1315 Jesse Jewell Parkway 1404 River
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive Florence, Alabama
Pediatric Dental Clinic David H. Merritt, D.M.D., M.S., P.C. 162 Ana drive 256-766-0270 Father: DOB: SS#: Home Address: Home #: Work #: Cell #: Employed By: Address: Do you have dental insurance? Yes No