Patient Information. Last Name: First Name: Middle Initial: Address: Address 2: City: State: Zip: Primary Phone: Work Phone:

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Julianna Hicks
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1 Patient Information Last Name: First Name: Middle Initial: Address: Address 2: City: State: Zip: Primary Phone: Work Phone: SSN: DOB: Gender: Male Female Marital Status: Single Married Divorced Separated Widowed Race: American Indian/Alaskan Native Asian/Pacific Islander Black White Multi-racial Ethnicity: Hispanic Non-Hispanic Decline to answer Primary Language: Family Physician: Primary Insurance: Insurance Address: Insurance ID#: Secondary Insurance: Insurance Address: Insurance ID#: Referring Physician: Policy Holder Name: Policy Holder DOB: Policy Holder SSN: Group/Policy#: Policy Holder Name: Policy Holder DOB: Policy Holder SSN: Group/Policy#: Reason for appointment: Date of first symptoms: Was the onset of your pain: Sudden/Abrupt Gradual What caused your current pain episode? Assault Lifting Weight Lifting Exercise Motor Vehicle Accident Unknown Injury Surgery Injury at Work Trauma Frequency of your pain: Intermittent Constant Since your pain began, how has it changed? Increased Decreased No change Is the pain at its worst: Morning Afternoon Evening Night

2 Patient Information Use this diagram to indicate the location of your pain. Mark the drawing with the letters below to describe the pain you are experiencing. N S B P A Numbness Stabbing Burning Pins & Needles Aching Where is your worst pain located? Does this pain radiate? If so, where? List any additional areas of pain: Mark all of the prior treatments you have had to treat your pain: Acupuncture RFA (Radiofrequency Ablation) Chiropractor Trigger Point Injection Epidural Steroid Injection Spinal Cord Stimulator Trial Permanent Implant Joint Injection Vertebroplasty/Kyphoplasty Level(s) Nerve Block Pain Pump - Type Date Implanted Pain Medication Other: Physical Therapy Psychological Therapy I have not received any treatments for my pain Mark all of the prior diagnostic testing you have had related to your pain. List what area of the body, date of the test and the location of the facility that performed the test: Test Body Area Date Facility Location CT Scan EMG/NCS MRI X-ray Other: I have not received any diagnostic testing for my pain

3 Patient Information If you have used, or are currently using medication to treat your pain, please indicate which medications below: NSAID and Pain Medication Buprenorphine Fentanyl Methadone Norco Tramadol Celebrex Fioricet Mobic Opana Tylenol #2, #3, #4 Codine Hydrocodone Morphine OxyCodone Ultram Darvocet Ketamine Motrin OxyContin Vicoden Demerol Lorcet MS Contin Percocet Vicoprofen Dilaudid Lortab Naprosyn/Naproxen Suboxone Zydone Anxiety and Depression Medication Abilify Celexa Elavil Nortiptyline Valium Amitriptyline Clonazepam Klonopin Paxil Wellbutrin Ativan Cymbalta Lexapro Prozac Xanax Aventyl Effexor Luvox Restoril Zoloft Muscle Relaxants Baclofen Flexeril Norflex Skelaxin Cyclobenzaprine Metaxalone Robaxin Soma Anticonvulsants Gabapentin Lyrica Pregabalin Topamax Lamictal Neurontin Tegretol Topiramate Patient Medical History Please indicate all conditions you currently have or have had in the past: Addiction/Substance Abuse Fibromyalgia Lupus Anemia Heart Disease Migraines Anxiety/Depression Hepatitis Multiple Sclerosis Arthritis High Blood Pressure Parkinson s Disease Asthma High Cholesterol Peripheral Nerve Disease Blood Clots HIV/AIDS Seizures Cancer type: Irregular Heartbeat Stroke/TIA COPD Kidney Issues Thyroid Issues Diabetes Liver Issues Tumor Location: Family Medical History Please indicate all conditions your blood relative currently has or has had in the past and indicate which relative: Addiction Fibromyalgia Lupus Anemia Heart Disease Migraines Anxiety/Depression Hepatitis Multiple Sclerosis Arthritis High Blood Pressure Parkinson s Disease Asthma High Cholesterol Peripheral Nerve Disease Blood Clots HIV/AIDS Seizures Cancer Irregular Heartbeat Stroke/TIA COPD Kidney Issues Thyroid Issues Diabetes Liver Issues Tumor

4 Patient Information Patient Surgical History Please list all prior surgeries, the approximate date of the surgery and the name of the facility it was performed (use additional paper if needed): Surgery Date Facility I have not had any surgery Are you currently pregnant? Yes No Have you ever had a reaction to anesthesia? Yes No Do you have a pacemaker? Yes No Please list ALL medications you are currently taking including prescriptions, over the counter medications, vitamins and herbal supplements (use additional paper if needed): Medication Dosage Times Per Day I do not take any medication Please list ALL allergies (medications, latex, contrast dye, shellfish, etc.) and the reaction: Allergen Reaction I do not have any allergies Pharmacy Name: Location: Phone:

5 Patient Information Social and Psychosocial History Please answer all questions: Do you live alone? Yes No If you are currently married, please describe your marriage: Good Average Fair Poor Do you have children? Yes No If yes, how many? Do they live with you? Yes No What is your employment status? Full Time Part Time Retired Unemployed Disabled How often do you exercise? Never Rarely Sometimes Regularly Do you drink alcohol? Yes No If yes, how many drinks do you consume per week? Do you use tobacco? Current Tobacco User Former Tobacco User Never Used Tobacco If you are a current tobacco user, what type of tobacco do you use? Cigarettes Chew Cigars Do you use recreational/street drugs? Current User Former User Has Never Used Do you drink caffeine? Yes No If yes, how many caffeinated drinks do you consume per day? Have you ever been treated for depression or an emotional/behavioral disorder? Yes No If yes, for what disorder? When? Do you currently have thoughts of suicide? Yes No Do you have a history of suicidal thoughts or attempts of suicide? Yes No Do you have a history of drug and/or alcohol abuse? Yes No Do you have a family history of drug and/or alcohol abuse? Yes No Describe your general stress level: Low Average High What do you do to cope with stress? What are your hobbies/interests? Who can you rely on for support?

6 Patient Name: Pain Questionnaire Please indicate the sentence in each section that best describes how pain affects your everyday life. Section 1 Personal Care Section 6 - Standing I can look after myself without causing pain I can stand as long as I like without pain I can look after myself normally, but it causes extra pain I can stand as long as I like but it causes pain It is painful to look after myself, but I am slow and careful Pain prevents me from standing longer than 1 hour I need some help, but manage most of my personal care Pain prevents me from standing longer than 30 minutes I need help every day in most aspects of self-care Pain prevents me from standing longer than 10 minutes I don t get dressed, I wash with difficulty and stay in bed Pain prevents me from standing at all Section 2 Pain Intensity (Current) Section 7 - Sleeping I have no pain I have no trouble sleeping The pain is mild My sleep is slightly disturbed by pain (less than 1 hour of sleeplessness) The pain is moderate My sleep is mildly disturbed by pain (1-2 hours of sleeplessness) The pain is fairly severe My sleep is moderately disturbed by pain (2-3 hours of sleeplessness) The pain is very severe My sleep is greatly disturbed by pain (3-5 hours of sleeplessness) The pain is the worst imaginable Pain prevents me from sleeping at all Section 3 - Lifting Section 8 - Recreation I can lift heavy weights without pain I am able to do all of my usual recreational activities with no pain I can lift heavy weights but it causes extra pain I am able to do all or most of my usual recreational activities Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned with some pain I am able to do most, but not all of my usual recreational activities I am able to do only a few of my usual recreational activities I can only lift very light weights I am not able to do most of my usual recreational activities I can t lift or carry anything at all Pain prevents me from doing any of my usual recreational activities Section 4 - Driving Section 9 Social Life I can drive without pain My social life is normal and without pain I can drive as long as I want with slight pain My social life is normal, but increases the degree of pain I can drive as long as I want with moderate pain Pain has no significant effect on my social life except for limiting energetic interests (e.g. sports) I can only drive short periods because of moderate pain Pain has decreased my social life I can barely drive at all because of severe pain Pain has restricted my social life to my home I can t drive at all Pain prevents me from having a social life Section 5 - Sitting Section 10 - Traveling I can sit in any chair for as long as I like I can travel anywhere without pain I can only sit in my favorite chair as long as I like I can travel anywhere, but it causes pain Pain prevents me from sitting longer than 1 hour Pain is severe, but I can manage journeys over 2 hours Pain prevents me from sitting more than 30 minutes Pain restricts me to journeys of less than 1 hour Pain prevents me from sitting more than 10 minutes Pain restricts me to journeys under 30 minutes Pain prevents me from sitting at all Pain prevents me from traveling except to go to the doctor

7 Patient Acknowledgement and Authorization Patient Acknowledgement of Receipt of Privacy Practices The Notice of Privacy Practices explains how PA Spine Specialists may use and disclose your protected health information. By signing below, you acknowledge that you have received the Notice of Privacy Practices and have been given the opportunity to ask any questions that you may have. Patient/Guardian Signature Patient/Guardian Print Date Patient Authorization for Use and Disclosure of Protected Health Information PA Spine Specialists takes your privacy seriously. If you would like us to be able to disclose your protected health information to a friend or family member, please list their information below. You may revoke this permission at any time by submitting your request in writing to our office. Name Phone Relationship Name Phone Relationship

8 Patient Communications and Medication History Authorizations Patient Authorization for Automated Communications PA Spine Specialists uses an automated appointment reminder system. Our reminder system contact patients prior to their scheduled appointment via phone, text or to provide automated information pertaining to the upcoming appointment. These messages may contain the patient s name, contact information, date, time and location of the appointment and the name of the treating physician. The reason for your appointment will not be disclosed. Reminder messages that are delivered via phone will be played automatically when the call is answered. If the call is not answered and goes to an answering machine or voic , the message will be recorded. Please list your preferred method of contact below. By signing below, you acknowledge and accept the use of our automated reminder system. Home Phone Work Phone Cell Phone Patient/Guardian Signature Patient/Guardian Print Date eprescribing and Medication History E-Prescribing is a prescriber's ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point-of-care - is an important element in improving the quality of patient care. PA Spine Specialists utilizes this technology for better service to our patients. PA Spine Specialists also uses this technology to electronically obtain your medication history to help minimize the potential for drug interactions and adverse drug events. This information is stored in your medical record. By signing below, you acknowledge and authorize PA Spine Specialists to use eprescribe technology and to electronically obtain your medication history. Patient/Guardian Signature Patient/Guardian Print Date

9 Office Policies and Financial Agreement New Patients Please be sure to bring your photo identification and insurance card to every visit. The new patient paperwork must be completed prior to your first appointment. All necessary paperwork can be completed by downloading the forms from our website or by creating an account on the patient portal via our website. If you do not have access to a computer you may come into the office and complete the forms in person. Children Children 13 and under are not permitted in the exam room unless they are the patient. They may wait in the waiting room as long as they are accompanied by an adult. Children 14 and older are not permitted in the exam room unless they are the patient. They may wait in the waiting room unaccompanied. Consent for Treatment (Adults) Adult patients that are unable to communicate effectively, complete all necessary paperwork or consent to their own treatment due to serious illness or intellectual disability must be accompanied by their Power of Attorney (POA). If the POA has completed all necessary paperwork and has given permission to consent to treatment for the patient to another person or facility, then the POA need not be present. Nursing Home Patients Nursing home patients must have all paperwork completed and returned to our office no later than the day before the appointment. If we don t receive this paperwork, the appointment may need to be rescheduled. Late Arrival New patients need to arrive no later than 30 minutes prior to their scheduled appointment. Established patients need to arrive no later than 15 minutes prior to their schedule appointment. If you do not arrive at these times, your appointment may need to be rescheduled. No Show If you fail to give us notice and do not come in for your office appointment, you will be charged a No Show fee of $50. If you fail to give us notice and do not come in for your procedure, you will be charged a No Show fee of $75. Multiple no shows may result in discharge from the practice. Cancellations Office appointments must be cancelled at least 24 hours in advance. Procedures must be cancelled at least 48 hours in advance. Failure to provide the appropriate notice of cancellation will result in a broken appointment fee of $50 for an office appointment and $75 for a procedure. Multiple cancellations without proper notice may result in discharge from the practice. Copay Copays are collected at check in. Copays are determined by your insurance company and our office is contractually obligated to collect that amount at each visit. If you do not pay your copay at check in, your appointment may need to be rescheduled. Urine Drug Screens It is the policy of PA Spine Specialists to perform urine drug screens on all patients under the age of 68 at any or all office visits. In Office Testing and Procedures As part of your exam and ongoing care, we may perform tests or procedures in the office. Some tests and/or procedures may not be covered by your insurance. As with all services, you are responsible for all balances not covered by your insurance.

10 Office Policies and Financial Agreement Self-Pay New patients that do not have insurance must pay $350 for the initial office visit. Established patients must pay $150 for the office visit. You may pay via cash, certified check or credit card. Returned Checks A $35 fee will be charged for all returned checks. If you write a check to us and it is returned due to a stop payment or nonsufficient funds, we will no longer be able to accept your personal check as payment. Workers Comp/Motor Vehicle Accident Please be sure to provide all information on the Workers Comp/MVA Claim Form. We will also need to record your medical insurance information. Our office will bill Workers Comp or the MVA claim directly. If your claim is denied, we will bill your medical insurance. You are responsible for all balances not paid by your claim or medical insurance. Participating Insurances We will bill your medical insurance company directly. You are responsible for all copays, coinsurance and deductibles as required by your insurance. Forms Completion of standard short term disability, long term disability and FMLA forms will be charged $50. Nonstandard forms will be completed on a case by case basis. If your form requires that you have a Functional Capacity Evaluation, we will be happy to refer you to a licensed Physical Therapist who can perform this assessment. Should you require copies of your medical record, you will be charged the current Pennsylvania Department of Health per page rate in addition to the cost of the form. Handicap Placards We will complete this form at no charge. By signing below, I acknowledge that I have read, understood and agree to the above policies. I authorize PA Spine Specialists to release all necessary information to my insurance carrier for the purpose of processing my claim(s). I am assigning my medical benefits to PA Spine Specialists and authorize my insurance carrier to pay PA Spine Specialists directly for all services rendered. I understand that not all services are covered by insurance and that I am responsible for payment of all outstanding balances on my account. Patient/Guardian Signature Patient/Guardian Print Relationship to Patient Date

NEW PATIENT INFORMATION SHEET

Akintomi A. Olugbodi M.D. 301 S. Seventh Ave. Suite 315 West Reading, PA 19611 (484) 869-2817 NEW PATIENT INFORMATION SHEET PLEASE COMPLETE THESE FORMS PRIOR TO YOUR APPOINTMENT AND BRING THEM WITH YOU