Welcome to Missouri Spine and Pain Management. Patient Last Name: First Name: City: State: Zip Code: Other Address:

Transcription

1 Welcome to Missouri Spine and Pain Management Patient Last Name: First Name: Social Security # - - Sex: Male Female Previous Used and/or Nick Name: Date of Birth: Marital Status: Married Single Divorced Widowed Other Mailing Address: City: State: Zip Code: Other Address: Primary Care Provider: Referring Provider: Primary Language: English Spanish French Other Patient Race: (For Medical Purpose only, This is now a requirement for us to have on file) American Indian or Alaska Native Asian Native Hawaiian or other pacific island African American Other Race White Hispanic or Latin Refused to Report -----Preferred Contact Information----- Primary Telephone # - is this a Cell Landline Is it okay to leave a Message here? Yes, Extended O.K. to leave message with detailed information Yes, but Brief (Leave Message with call-back number only) No Secondary Telephone # - is this a Cell Landline Is it okay to leave a Message here? Yes, Extended O.K. to leave message with detailed information Yes, but Brief (Leave Message with call-back number only) No Address: 1

2 May we contact you through ? Yes No I do not have Would you like access to our Patient Portal? Yes No ----Emergency Contact Information---- Contact Name: Telephone # Relationship to Patient: ----Pharmacy Information---- Pharmacy Name: Pharmacy # Phamacy Address: Authorization and Consent To View RX History from External Source: I authorize Missouri Spine and Pain Management to view any and all available RX History from an External Source. I am aware that Missouri Spine and Pain Management uses a secure connection to SureScripts to send and receive prescriptions. (Signature of Patient, or Personal Representative) (Relationship to patient if not signed by patient) (This Authorization will remain in effect from dated signed until revoked in writing by patient or guardian) ----Patient Questionnaire---- Employment Status: Full-time Part-time Retired Unemployed Other Is your pain in result of a work injury or car accident: Yes No How did you Initially hear about our clinic? Website Card/Brochure Billboard Doctors office Other Do you currently see a Psychiatrist, Psychologist, or counselor? Yes No If Yes, Please Provide Name and Telephone number of Provider: 2

3 Have you ever been to a Pain Management Clinic in the past? Yes No If Yes, Please provide Name and Telephone Number of Provider: ----Insurance Information---- Primary Insurance: Co-Pay: Policy Holder s Name: Policy Holder s DOB: Secondary Insurance: Policy Holder s Name: Policy Holder s DOB: Other Insurance: Consent for Insurance Assignment/Payment: I hereby authorize the assignment of benefits (payments) directly to Missouri Spine and Pain Management LLC for all my insurance claims related to services received. I agree to pay any and all charges that exceed, or are not covered by my insurance. I understand that co-pays, deductibles and non-covered services are due at the time of service. I authorize the release of any medical information necessary for the purpose of processing claims with my insurance company. I permit a copy of this authorization to be used in place of the original. Signature of Responsible Party: Date: (Authorization will remain in effect from date signed until revoked in writing by patient or patient representative) ----Financial Policy---- We are pleased that you have chosen our practice for your pain management needs. We are committed to providing you with the highest quality care and achieving desired outcomes through collaborative effort. We would like to take this opportunity to thank you for allowing us to take care of you. In keeping with our philosophy of open communication and education, it is important that you understand the financial policies of the practice. It is equally important that you understand the terms of YOUR medical coverage. Although our staff is very knowledgeable of most insurance plans, it is important that you understand the details and terms of your personal plan. Typically you will find the insurance company s phone number on the back of your insurance card and we encourage you to contact them with questions specific to YOUR coverage. If you have Medical Insurance Benefits: 3

4 If you have an insurance plan that requires a referral, you must contact your Primary Care Physician PRIOR to receiving care from a specialty provider. Regretfully, many insurers will not cover specialty services that are rendered without a referral and you may be held responsible for the costs. If we do not have a referral on file, we will not be able to render services. We participate in most major health plans and our business office will submit claims for services rendered. It is the patient s responsibility to provide all necessary information to file the claims prior to leaving our office. We will file your primary and secondary insurance claims and work diligently with the carrier to resolve any conflicts that may arise. However, your insurance company may need you to supply certain information directly. It is your responsibility to comply with this request. Please bring your insurance cards to EACH and EVERY visit to our office. Your insurance company REQUIRES us to collect co-payments at the time services are rendered. Failure to collect or waiver of your co-payment may constitute fraud under state and federal law. Please be prepared to pay your co-payment on the date services are rendered as this is a requirement per your insurance carrier. If you do not have your co-payment, we are not required to see you. Additionally, you may have coinsurance and/or deductible amounts required by your insurance carrier. Any outstanding balance on your account following insurance processing will be billed to you. It is the policy of the practice to treat ALL patients in an equitable fashion related to account balances. The practice will NOT waive or fail to collect any co-payments, co-insurance, deductibles, or other patient financial responsibility in accordance with state and federal law as well as participating agreements with payers. Full or partial financial responsibility may only be waived in accordance with the practice s Financial Hardship Policy. Patient Balances: Any patient balances that remain delinquent after 90 days, with no response to requests, payment, may be referred to a collection agency. You will be responsible for any and all costs associated with the collection agency up to and including all legal costs. Patients with account balances in excess of 120 days with no payment arrangements or hardship request may be discharged from the practice. If this occurs you will have 30 days to seek alternative medical care. During the 30 day period our physicians will only be able to treat you on an emergency basis. For your convenience, our office accepts the following payment methods: Money order --- Check --- Cashier s Check -- Cash --- Credit Card (Except self pay patients: Cashier s Check, Check or credit card only can be accepted for payment per state regulations) Returned checks will be charged a $50.00 fee. PLEASE READ THE ABOVE FINANCIAL POLICY CAREFULLY BEFORE SIGNING I, the undersigned, understand the financial policies of Missouri Spine and Pain Management, and agree to abide by the plan I have signed. In addition, I understand and agree to the following. To pay the amount charged by Missouri Spine and Pain Management for all professional treatment and services to the undersigned. I understand that I am financially responsible for any and all charges whether or not they are covered by insurance. In the event that I do not pay all cost of collection and reasonable legal fees in addition to the amount originally owed. 4

5 If genuine financial difficulties exist, please call our office. We are happy to work with you in resolving your balance and may be able to set up payment arrangements. Signature of Patient or Representative Date ----Acknowledgment of Receipt of HIPPA Notice---- Missouri Spine and Pain Management is concerned about the privacy of our patient s health care information. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care service will in no way be conditioned upon your signed acknowledgment. If you decline to provide a signed acknowledgment, we will continue to provide your treatment, and will use and disclose your protected health information for treatment, payment, and health care operations when necessary. I acknowledge that I have received the Notice of Privacy Practices for: Missouri Spine and Pain Management (Signature of Patient or Legal Guardian) (Date) ----Authorization To Discuss Your Medical Information---- In accordance with the HIPAA guidelines Missouri Spine and Pain Management is authorized to discuss my medical information with the following individuals. Please list up to 3 people we may leave messages with in the event we are unable to contact you. Person s Name Relationship to Patient Telephone Number (Signature of Patient or Legal guardian) (Date) (Relationship to Patient if Not Patient) 5

6 Patient Pain Evaluation Please tell us the first and last name of your Primary Care Provider: What is your Primary Complain? ( only select one): Abdominal Pain Arm pain Buttock Pain Chest Pain Hand Pain Headache Hip Pain Face Pain Foot Pain Groin Pain Knee Pain Leg Pain Low Back Pain Mid Back Pain Neck Pain Shoulder Pain Tailbone Pain Total Body Pain If you are a female, please tell us your pregnancy status: Hysterectomy Post-Menopausal Not able to get pregnant Child- bearing age- No Child-bearing age- Birth control Child-bearing age- other contraception medication contraception When did your pain first begin, please tell us a month and year if known? Mm/yyyy What is the main cause of your pain? Unknown Normal Aging Fail Sporting Accident Motor Vehicle Accident Work Injury Other: What is the Frequency of your pain? Constant Fluctuating but always present What best describes your pain? Fluctuating but usually present Fluctuating and rarely present Aching Burning Cramping Dull Numb Sharp Stabbing Stinging Throbbing Tingling What is your pain Level most of the time? What makes your pain worse? Bending or Stooping Changing from sitting to standing Sitting Lifting or carrying heavy loads Lifting or carrying small loads Lying on back Lying on Side Nothing What makes your pain better? Lying on side Lying on Back Sitting Standing Walking Stretching Exercise Nothing What interferes with your pain? Daily Chores Employment Exercise Grooming House Chores Mood Sleep Relationships Walking Nothing 6

7 Have you had any of the following imaging/test to assist in the evaluation of your pain? Procedure/Test No Yes, if yes when and where MRI CT Scan X-Ray EMG/Nerve Conduction Genetic Testing Blood work related to pain Drug Screen Bone Scan Bone Density Vascular Studies Functional Capacity Exam Depression Screening Have you ha any of the following injections to assist with the treatment with your pain? Spinal Joint Muscle None Have you had any of the following related to your pain? Back Brace Neck Brace Tens unit None Have you had any of the following surgeries? Low Back Mid Back Neck Hip Knee Shoulder None Have you had any of the following therapies to assist with treatment of your pain? Physical Therapy Chiropractic Therapy Aquatic Therapy None Have you had or done any of the following to assist with the treatment of your pain? Spinal Cord Stimulator Spinal Traction Cane Walker Exercise Program Weight Loss Program None Patient Medication History Please tell us if any of the following Anti0 Inflammatory Medications have been helpful? None Tried Aspirin Celebrex Diclofenac Daypro Etodalac (Lodine) Ibuprofen(Motrin, Indomethacine Ketroprofen Mobic (Meloxicam) Advil) (indocin) Naproxen (Naprosyn, Aleve, Anaprox) Relafen Toradol Tramado l(ultracet) Please tell us if any of the following Muscle Relaxer medications have been helpful? Baclofen Cydobenzabrine Carisoprodol ( Soma) Diazepam (Valium) Methocarbalmol (Flexeril) (Robaxin) Norflex Parafon Forte Skelaxin Tizanidine (Zanaflex) None Tried 7

8 Please tell us if any of the following Narcotic Medications have been helpful? Avinza Codeine Durgesic Dilaudid (Hydromorphone) Hydrocodone ( Norco, Kadian Opana Oxycontin Lortab, Lorcet) Oxycodone (Percocet) MSIR Methadone Morphine Sulfate ( MS Contin, Avinza, Kadian) Tramadol (Ultracet) None Tried Please tell us if any of the following have been helpful: Biofreeze IcyHot Bengay Aspircreme Emla Cream Voltren Gel Compounded Pain Cream Please tell us if any of the following other Medication shave been helpful? Cymbalta Conidine Elavil (Amitriptyline) Keppra Klonopin Lidoderm Patch Lyrica Neurontin Savella Topamax Trileptal Zonegran Please List all the medications you are currently taking, include dose and frequency: Past Medical History ( Please select all that apply): Patient Medical History Migraine High Blood Emphysema Cirrhosis Kidney Disorder Cancer Headaches Pressure Head Injury High Cholesterol Asthma Hepatitis Prostate Disorder Depression Stroke Coronary Artery Sleep Apnea Gallbladder DZ Osteoporosis Anxiety Disease Seizures Heart Attack Hiatal Hernia Pancreatitis Spine Disorder Alcoholism Multiple Sclerosis Heart Arrhythmia Reflux Diabetes Arthritis OA/RA Addiction Peripheral Nerve Disease Ulcers Bowel Disease Muscle Disorder Please List Any Allergies : Please List Any Past Surgical History: 8

9 Family Medical History: Migraine High Blood Emphysema Cirrhosis Kidney Disorder Cancer Headaches Pressure Head Injury High Cholesterol Asthma Hepatitis Prostate Disorder Depression Stroke Coronary Artery Sleep Apnea Gallbladder DZ Osteoporosis Anxiety Disease Seizures Heart Attack Hiatal Hernia Pancreatitis Spine Disorder Alcoholism Multiple Sclerosis Heart Arrhythmia Reflux Diabetes Arthritis OA/RA Addiction Peripheral Nerve Disease Ulcers Bowel Disease Muscle Disorder What is your marital status? Patient Social History Who Resides in your home or assist in your care if needed? If residing in a Skilled Nursing Home or Under Hospice Care, What is the Facility /Company Name: What is your employment status: Smoking Status: Alcohol Use: Do you have any street drug use? No Yes Preventative Medicine: Falls Risk Screening: If you are 65 or older, please mark all that apply to you: No Falls in the past year One fall with injury in the past year One fall without injury in the past year Two or more falls with injury in the past year Two or more falls without injury in the past year 9

10 Review of Systems: Review of Systems: Please mark each of the following symptoms/problems that you currently have ( Mark all that Apply): GENERAL HEENT RESPIRATORY CARIDOLOGY GASTROENTEROLOGY Weight Loss Headache Chronic Cough Chest Pain Appetite Loss Weight Gain Facial Pain Wheezing Irregular Chronic Nausea Heartbeat Fever Sinusitis Shortness of Breath Murmur Heartburn Night Sweats Loss of Vision Sleep Apnea Congestive Constipation Failure Fatigue Hearing Loss Home Oxygen Use Abnormal EKG Diarrhea Many Infections Teeth/Gum C-PAP High Blood Bowel Control Loss Problems Pressure GENITOURINARY ENDOCTINE/HEM MUSCULOSKELETAL NEUROLOGY PSYCHIATRIC Painful Urination Abnormal Blood Joint pain Drowsiness Depression sugars Blood in Urine Easy Muscle Spasm Dizziness Anxiety Brusing/Bleeding Bladder control loss VASCULAR Neck Pain Blackouts Panic Attacks Enlarged Prostate Poor Circulation Back Pain Seizures Insomnia Testicular Pain Current Blood Clot Tremors SKIN Irregular Bleeding Swelling in Legs Weakness Rash Pregnancy Numbness Family History (parents and siblings): ----Opioid Risk Tool---- Male Female Alcohol abuse (3) (1) Illegal drug use (3) (2) Prescription drug abuse (4) (4) Personal History: Alcohol abuse (3) (3) Illegal drug use (4) (4) Prescription drug abuse (5) (5) Mental Health: Diagnosis of depression (1) (1) Diagnosis of ADD, OCD, bipolar, schizophrenia (2) (2) Other: Age 16 years old to 45 years old (1) (1) History of pre-adolescent sexual abuse (0) (3) Total 10

11 Please make the appropriate column Have you taken/used any of the following in the last 2 months? Cocaine Marijuana Methamphetamine Methadone Suboxone/Subutex Opana Insomnia(Sleeping) Medication Anxiety Medication ( Such as Xanax, Valium, Klonopin, Ativan, ETC.) Morphine Hydrocodone ( Lortab, Norco, Vicodin) Oxycodone (Percocet, Oxycontin, Roxicodone, ETC.) Heroin Any Prescription medication that was not prescribed to you? Yes No 11

12 Oswestry Pain Disability Questionnaire Please complete this questionnaire. It is designed to tell us how your back pain affects your ability to function in everyday life. I have Chronic Pain or pain that has bothered me for 3 months or more: Yes or No *Please answer each section below by checking the One Choice that applies the most to you at this time. (You may feel that more than one of the statement relates to you at this time, but it is very important that you please check only one choice that best describes your problem at this time. Section 1: Pain Intensity I can tolerate the pain I have without having to use pain killers. [0 points] The pain is bad but I manage without taking pain killers. [1 point] Pain killers give complete relief from pain. [2 points] Pain killers give moderate relief from pain. [3 points ] Pain killers give very little relief from pain. [4 points] Pain killers have no effect on the pain and I do not use them. [5 points] Section 2: Personal Care I can look after myself normally without causing extra pain. [0 points] I can look after myself normally but it causes extra pain. [1 point] It is painful to look after myself and I am slow and careful. [2 points] I need some help but manage most of my personal care. [3 points] I need help every day in most aspects of self care. [4 points] I do not get dressed wash with difficulty and stay in bed. [5 points] Section 3: Lifting I can lift heavy weights without extra pain. [0 points] I can lift heavy weights but it gives extra pain. [1 point] Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned for example on a table. [2 points] Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. [3 points] I can lift only very light weights. [4 points] I cannot lift or carry anything at all. [5 points] 12

13 Section 4: Walking Pain does not prevent me walking any distance. [0 points] Pain prevents me walking more than 1 mile. [1 point] Pain prevents me walking more than 0.5 miles. [2 points] Pain prevents me walking more than 0.25 miles. [3 points] I can only walk using a stick or crutches. [4 points] I am in bed most of the time and have to crawl to the toilet. [5 points] Section 5: Sitting I can sit in any chair as long as I like. [0 points] I can only sit in my favorite chair as long as I like. [1 point] Pain prevents me sitting more than 1 hour. [2 points] Pain prevents me from sitting more than 0.5 hours. [3 points] Pain prevents me from sitting more than 10 minutes. [4 points] Pain prevents me from sitting at all. [5 points] Section 6: Standing I can stand as long as I want without extra pain. [0 points] I can stand as long as I want but it gives me extra pain. [1 point] Pain prevents me from standing for more than 1 hour. [2 points] Pain prevents me from standing for more than 30 minutes. [3 points] Pain prevents me from standing for more than 10 minutes. [4 points] Pain prevents me from standing at all. [5 points] Section 7: Sleeping Pain does not prevent me from sleeping well. [0 points] I can sleep well only by using tablets. [1 point] Even when I take tablets I have less than 6 hours sleep. [2 points] Even when I take tablets I have less than 4 hours sleep. [3 points] Even when I take tablets I have less than 2 hours of sleep. [4 points] Pain prevents me from sleeping at all. [5 points] Section 8: Sex Life My sex life is normal and causes no extra pain. [0 points] My sex life is normal but causes some extra pain. [1 point] My sex life is nearly normal but is very painful. [2 points] 13

14 Section 8: Sex Life Continued My sex life is severely restricted by pain. [3 points] My sex life is nearly absent because of pain. [4 points] Pain prevents any sex life at all. [5 points] Section 9: Social Life My social life is normal and gives me no extra pain. [0 points] My social life is normal but increases the degree of pain. [1 point] Pain has no significant effect on my social life apart from limiting energetic interests such as dancing. [2 points] Pain has restricted my social life and I do not go out as often. [3 points] Pain has restricted my social life to my home. [4 points] I have no social life because of pain. [5 points] Section 10: Traveling I can travel anywhere without extra pain. [0 points] I can travel anywhere but it gives me extra pain. [1 point] Pain is bad but I manage journeys over 2 hours. [2 points] Pain restricts me to journeys of less than 1 hour. [3 points] Pain restricts me to short necessary journeys under 30 minutes. [4 points] Pain prevents me from traveling except to the doctor or hospital. [5 points] 14

15 Pain Management Consent Agreement----- The purpose of this consent agreement is to comply with the law regarding controlled pharmaceuticals and to prevent any misunderstandings about any controlled medication you may be given for pain. Please initial to indicate that you have read and/or have had the information explained on to you on each line. *I agree to submit to a blood, urine or saliva test, if requested by my Provider, to determine compliance with my program of pain medication. *I understand that my first office visit may be a consultation only and no pain medication given at that time if further investigation and/or testing deemed necessary. *I understand that I may be called at any time to bring all prescribed medication for a mandatory pill count within a specified time period (usually 24 hours). *I understand that I am to bring my medications prescribed by MSA in their original bottles to EVERY Appointment. I am to bring the bottle even if it s empty. *I agree that I will use my medications ONLY as prescribed by my doctor. I understand that any change to my prescriptions will require an office visit. I understand that self-medicating is not tolerated. No refills will be made during evenings or weekends. *I will not use any illegal substances, including marijuana, cocaine, etc. *I understand that lost or stolen medication or unfilled prescriptions WILL NOT be replaced, and I will safeguard my medication from theft. *I will not share, sell or trade my medications with anyone. *I will not alter the form of the medication nor will I take the medication in a route other than as prescribed by my provider. *I will not attempt to obtain controlled medication from any other provider, nor will I borrow or buy medication from any other person. *In the event of an emergency, if I do obtain controlled substances from another provider, I understand I am required to disclose this information to MSA within 48 hours of discharge or emergency service. I understand it is my responsibility to make sure MSA is notified of any such treatments and that I am to check with MSA before combining any pain medication with the prescriptions MSA provides me. *I will notify MSA of any change in name, address or phone number. I understand that I must at all times have an updated phone number with my provider. I cannot be on dangerous medications, such as opioids, if my provider cannot reach me in a reasonable period of time (usually considered within 24 hours of the initial attempt). I agree to return any phone call from MSA within 24 business hours. *I authorize my provider to investigate fully any possible misuse of my pain medication using any city, state or federal law enforcement agency, including this state s Board of Pharmacy. *I understand that any follow-up appointment may be scheduled with a Licensed Nurse Practitioner or Physician Assistant. Additionally I understand that refusing to see one of MSA providers will likely result in my no longer being able to be treated by the practice. *Once a prescription has been filled, all questions regarding that prescription should be directed to that pharmacy. *I understand that MSA does not mail prescriptions under any circumstances. *I understand that with any controlled substance that is prescribed to me there are inherent risks, namely loss of efficacy over time, symptoms of withdrawal if abruptly stopped, and addiction;

16 medication taken in excess (this is different for everyone ranging from the prescribed dose to taking more than prescribed or combining with other controlled substances or even alcohol) may result in respiratory suppression or failure or death; sedation, loss of function, impairment may also occur I agree not to drive while under the influence of any prescribed controlled substance; constipation, allergic reaction, itching, nausea and dry mouth are also common side effects; my immune system may be suppressed and my hormone levels may decrease over time while being on chronic opioids. * I understand that the combination of controlled substances and alcohol are contra-indicated; the combination may result in serious harm or even death. *I understand that non-professional or inappropriate behavior toward any MSA staff, affiliate or provider will not be tolerated. I agree to be respectful to other patients I may encounter in the waiting room, lobby, hallways, etc. I understand that I may not loiter in the parking lot of any MSA location. *I understand that there may be a medication prescribed or administered to me that is a compounded medication these are compounded by specialty pharmacies and are regulated differently than typical medications found stocked on shelves at commercial pharmacies. If I have questions regarding any of these, MSA is able to provide pharmacy information upon request. * I understand that by missing appointments or cancelling/rescheduling with less than 24 hours advance notice may result in the provider determining that I am unwilling or unable to comply with the treatment plan determined to be the best option for my care. Fee will be charged of $25.00 for no show fee for appointments and $50.00 for missed procedures, no exceptions. * I understand that non-compliance with my pain management treatment plan may result in providers inability to properly treat my symptoms and could cause symptoms to worsen or become life threatening. * Due to the severity of the outcome of my non-compliance, I understand that I may be released from MSA for missing appointments or cancelling/rescheduling appointments with less than 24 hour notice. I agree that the goals of pain management have been explained to me as to what is considered appropriate and reasonable and that alternative treatment plans, outside of use of controlled pain medications, have been made available to me. I have agreed to proceed with pain management after a full explanation of the risks and benefits. I understand if I break this agreement, it will result in a change in my treatment plan, including safe discontinuation of my opioid medications when applicable or complete termination of the provider/patient relationship. I understand that I am only to use the pharmacy listed below for all my medication needs with MSA or any other provider and that information will be shared between MSA and my pharmacy to process the prescription: Pharmacy Name: Pharmacy Telephone: PharmacyAddress: I have read and/or this information has been explained to me and I understand the terms of this agreement: Signature of Patient or Legal Representative: Date: 16