New Patient. Patient Information. Referral. Primary Care Provider PCP Phone #: Referring Provider Ref Phone #: Date of Birth: Age: Gender: Male Female

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Madlyn Jordan
5 years ago
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New Patient Patient Information Today's Date: Today s Provider: Your Name: Social Security Number: Date of Birth: Age: Gender: Male Female Street Address: City/State/Zip: Physical Address Same as

1 New Patient Patient Information Today's Date: Today s Provider: Your Name: Social Security Number: Date of Birth: Age: Gender: Male Female Street Address: City/State/Zip: Physical Address Same as Mailing? Yes No If not, please list mailing address: Marital Status: Married Single Divorced Widowed Other: Occupation: City: Driver s License # State: Preferred Phone: Home Mobile Work Secondary Phone: Home Mobile Work Emergency Contact Name: Phone: Relation: Permission to discuss Personal Health Information: Yes No Referral Primary Care Provider PCP Phone #: Referring Provider Ref Phone #: How did you hear about us? TV Radio Insurance Company Family Friend Physician Facebook Twitter YouTube Another Website

2 Primary Insurance Plan Payer (e.g. BC/BS): Policy/I.D. Number: Plan: Group Number: Insurance Policy Holder: Self Spouse Child Other: Policy Holder Nam e: Policy Holder Gender: Male Female Date of Birth: Social Security Number: Secondary Insurance Plan (if any) Payer (e.g. BC/BS): Policy/I.D. Number: Plan: Group Number: Insurance Policy Holder: Self Spouse Child Other: Policy Holder Nam e: Policy Holder Gender: Male Female Date of Birth: Social Security Number: Workers Compensation Claim Information Complete this section only if your visit today is related to a Workers Compensation claim. N/A Workers Comp Company: Agent Name: State of Injury: Phone number: Claim Number: Fax number: Date of initial injury: Injury Claim Is your pain the result of a motor vehicle accident or other accident, which occurred within the last two years, and was caused by the fault or negligent of another? Yes No N/A Have you hired an attorney for purposes of making any claims arising from that accident? Yes No **If yes to either question, you will be asked to complete two additional forms. I certify that the information on this form is accurate, complete and true. Patient Signature: Date:

3 Clinical Information Today's Date: Today s Provider: Your Name: Date of Birth: Height: Weight: BP: Temp: Preferred Pharmacy Pharmacy Name: Phone Number: Street Address: City: State: Zip: Pain Description Use the pain scale described below to rate your pain for the questions below: 0 - Pain-free 1 - Very minor annoyance, occasional minor twinges 2 - Minor annoyance, occasional strong twinges 3 - Annoying enough to be distracting 4 - Can be ignored if you are involved in your work/task, but still distracting 5 - Cannot be ignored for more than 30 minutes 6 - Cannot be ignored for any length of time but can still go to work and participate in social activities 7 - Makes it difficult to concentrate, interferes with sleep, but you can still function with effort 8 - Physical activity 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 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? Where is your worst area of pain located? Does this pain radiate? If so, where? Please list any additional areas of pain:

4 Onset of Symptoms Approximately when did this pain begin? What caused your current pain episode? How did your current pain episode begin? Gradually Suddenly Since your pain began, how has it changed? Decreased Increased Stayed the same Use this diagram to indicate the location and type of your pain. Mark the drawing with the following letters that best describe your symptoms: "N" = numbness "S" = stabbing "B" = burning "P" = pins and needles "A"= aching Pain Description - Check all the following that describe of your pain: Aching Cramping Dull Hot/Burning Numbness Shock-like Shooting Spasms Squeezing Stabbing/Sharp Throbbing Tingling/Pins & Needles Tiring/Exhausting Factors that Affect your Pain Increases Pain Decreases Pain No Change Bending Backward Bending Forward Changes in Weather Climbing Stairs Coughing / Sneezing Driving Lifting Objects Looking Forward Looking Downward Looking Side to Side Rising from a Seated Position Sitting Standing Walking What other factors worsen or affect you pain that is not listed above?

5 Pain Frequency What word best describes the frequency of your pain? Constant Intermittent When is your pain at its worst? Mornings During the day Evenings Middle of the night Mark all of the following activities that are adversely/negatively affected by your pain Enjoyment of Life Normal Work General Activity Recreational Activities Mood Relationship with people My goal is to resume normal activities Sleep Walking Other: In the past three months, have you developed any new conditions? I Have Not Recently Developed Any New Conditions Balance Problems Fevers Difficulty Walking Sleep Numbness/Tingling - Where? Nausea Chills Others: Vomiting Bowel incontinence Pain Treatment History Please mark and list what previous pain treatments you have had (approximate dates): I Have Not Had Any Prior Treatments for My Current Pain Complaints Physical Therapy How many sessions? Date: Chiropractic How many sessions? Date: Psychological Therapy How many sessions? Currently in Therapy Not in Therapy Injection Therapy If so, list: Date: Spinal Cord Stimulator Trial Only Permanent Date of Implant: Do you currently use it? Yes No Do you obtain relief? Yes No Date: Date: Date: Date: Spine Surgery Type: Date: Weight Loss Program: Type: Other:

6 Diagnostic Tests and Imaging What imaging/tests have you had done for your pain complaint? I Have Not Had Any Diagnostic Tests Performed for My Current Pain Complaints Date Facility Past Surgical History Please indicate any surgical procedures you have had done in the past, including the date, type, and any pertinent details. I Have Not had any Surgical Procedures Performed Abdominal Surgery Gallbladder removal Appendectomy Joint Surgery Shoulder Hip Other Female Surgeries Caesarean section Hysterectomy Laparoscopy Ovarian Other Heart Surgery Valve replacement Aneurysm repair Other Knee Spine / Back Surgery Discectomy (levels) Laminectomy Spinal fusion (levels) Other Common Surgeries Hemorrhoid surgery Hernia repair Thyroidectomy Tonsillectomy Vascular surgery Please list any other surgeries and dates (attach an additional sheet if necessary):

7 Current Medications Are you taking a prescribed blood-thinner medication? Yes No If yes, please check which one: Aggrenox Coumadin Effient Eliquis Lovenox Plavix Pleta Pradaxa Ticlid Warfarin Xarelto Other Please list ALL medications you are currently taking. Attach an additional sheet, if required. Medication Name Dose Frequency Medication Name Dose Frequency Who and approximately when was the last provider to prescribe you pain medications or other controlled substances? Attach an additional sheet, if required. Allergies Do you have any known drug allergies? Yes No If so, please list all medications you are allergic to. Medication Name: Allergic Reaction Type: Please check if you are allergic to: Iodine or Tape *Are you allergic to latex? Yes No *If yes, you will be asked to complete a separate questionnaire

8 Family History Mark all appropriate diagnoses as they pertain to your biological MOTHER AND FATHER only. Mother Father I I I I I I I I I I I I I I Other medical problems: Have No Significant Family Medical History I Am Adopted (No Medical History Available) Social History Are you capable of becoming pregnant? Yes No If so, are you currently pregnant? Yes No Highest level of education obtained: Grammar High School College Post-graduate Alcohol Use: Current Alcoholism Daily Limited Alcohol Use History of Alcoholism Never Drinks Alcohol Social Alcohol Use Tobacco Use: Current Tobacco Former Tobacco User Never Used Tobacco Drug Use: Denies Any Illegal Drug Use Currently Using Illegal Drugs (Which: ) Currently Using Someone Else's Prescription Medication Formerly Used Illegal Drugs (not currently using) (Which: ) Have you ever abused narcotic or prescription medications? Yes No (Which: ) Have you ever been discharged from a pain management practice in the past? Yes No If so, please explain: Which practice? 8

9 Past Medical History Mark the following conditions/diseases that you have been treated for in the past: General Medical Respiratory Genitourinary/Nephrology Cancer - Type Asthma Bladder Infection(s) Diabetes - Type Bronchitis Dialysis HIV / AIDS Emphysema/ COPD Kidney Infection(s) Pneumonia Kidney Stones Head/Eyes/Ears/Nose/Throat Tuberculosis Urinary Incontinence Glaucoma Headaches Head Injury Hyperthyroidism Valley Fever Gastrointestinal Bowel Incontinence Hepatic Hepatitis A Hypothyroidism Acid Reflux (GERO) Hepatitis B Migraines Cardiovascular/ Hematologic Anemia Bleeding Disorders Gastrointestinal Bleeding Constipation Musculoskeletal Amputation (active / inactive / unsure) (active / inactive / unsure) Hepatitis C (active / inactive / unsure) Neuropsychological Coronary Artery Disease Bursitis Alcohol Abuse Heart Attack Carpal Tunnel Syndrome Alzheimer Disease High Blood Pressure Chronic Low Back Pain Bipolar Disorder High Cholesterol Chronic Neck Pain Depression Mitral Valve Prolapse Chronic Joint Pain Epilepsy Murmur Fibromyalgia Prescription Drug Abuse Pacemaker/Defibrillator Joint Injury Multiple Sclerosis Phlebitis Osteoarthritis Paralysis Poor Circulation Osteoporosis Peripheral Neuropathy Stroke Phantom Limb Pain Schizophrenia Rheumatoid arthritis Tennis Elbow Vertebral Compression Fracture Seizures Reflex Sympathetic Dystrophy/CRPS Other Diagnosed Conditions 9

10 Review of Symptoms Mark the following symptoms that you currently suffer from. Note: Diagnosed conditions/diseases should be noted under Past Medical History above. Constitutional: Chills Difficulty Sleeping Easy Bruising Excessive Sweating Insomnia Excessive Thirst Low Sex Drive Fatigue Night Sweats Unexplained Weight Gain Unexplained Weight Loss Weakness Eyes: Recent Visual Changes Fevers Ears/Nose/Throat/Neck: Nosebleeds Dental Problems Recurrent Sore Throats Earaches Ringing in the Ears Hearing Problems Sinus Problems Cardiovascular: Bleeding Disorder Fainting High Blood Pressure Shortness of Breath During Sleep Chest Pain Irregular Heartbeat Swelling in the Feet Deep Vein Thrombosis Lightheadedness Respiratory: Cough Wheezing Pulmonary Embolism Shortness of Breath on Exertion/Effort Shortness of Breath at Rest Gastrointestinal: Abdominal Cramps Coffee Ground Appearance in Vomit Hernia Vomiting Acid Reflux Dark and Tarry Stools Constipation Diarrhea Musculoskeletal: Joint Swelling Back Pain Muscle Spasms Joint Pain Neck Pain Joint Stiffness Genitourinary/Nephrology: Blood in Urine Decreased Urine Flow/Frequency/Volume Erectile Dysfunction Neurological: Instability When Walking Psychiatric: Suicidal Thoughts Flank Pain Carpal Tunnel Syndrome Numbness/Tingling Depressed Mood Suicidal Planning Painful Urination Dizziness Seizures Feeling Anxious Pelvic Pressure Headaches Stress Problems

11 Global Pain Scale Please answer all questions INSTRUCTIONS: For each question, please indicate your response by circling a number from 0 to 10 YOUR PAIN: 0 = No Pain 10 = Extreme Pain For the past week, the best my pain has been For the past week, the worst my pain has been For the past week, my average pain has been For the past 3 months, my average pain has been YOUR FEELINGS: During the past week, I have felt: 0 = Strongly Disagree 10 = Strongly Agree Afraid Depressed Tired Anxious Stressed YOUR CLINICAL OUTCOMES: During the past week: 0 = Strongly Disagree 10 = Strongly Agree I had trouble sleeping I had trouble feeling comfortable I was less independent I was unable to work (or perform normal tasks) I needed to take more medication YOUR ACTIVITIES: During the past week, I was NOT able to: 0 = Strongly Disagree 10 = Strongly Agree Go to the store Do chores in my home Enjoy my friends and family Exercise (including walking) Participate in my favorite hobbies

12 OFFICE USE ONLY Mark Each that Applies item Score If Female Item Score if Male Family History of Substance Abuse: Alcohol Illegal Drugs Prescription Drugs Personal History of Substance Abuse: Alcohol Illegal Drugs Prescription Drugs Your Age (Mark box if 16-45) 1 1 Personal History of Preadolescent Sexual Abuse: Personal History of Psychological Disease: Attention Deficit Disorder, OR Obsessive Compulsive Disorder, OR Bipolar, OR Schizophrenia Depression 1 1 None of the above apply to me TOTAL

13 Medical History and Consent for Treatment I certify that the above information is accurate, complete and true. I authorize Innovative Pain and Wellness and any associates, assistants, and other health care providers it may deem necessary, to treat my condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness. I give my consent for Innovative Pain and Wellness to retrieve and review my medication history. I understand that this will become part of my medical record. I acknowledge that I have had the opportunity to review Innovative Pain and Wellness Notice of Privacy Practices, which is displayed for public inspection at its facility and on its website. This Notice describes how my protected health information may be used and disclosed, and how I may access my health records. I authorize Innovative Pain and Wellness to release my Protected Health Information (medical records) in accordance with its Notice of Privacy Practices. 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 Innovative Pain and Wellness to release any information required in obtaining procedure authorization or the processing of any insurance claims. I understand that Innovative Pain and Wellness will not release my Protected Health Information to any other party (including family) without my completing a written "Patient Authorization for Use and Disclosure of Protected Health Information" form, available at its facility and on its website. If I am asked to provide a urine, oral swab 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 time with written notification and is valid until 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 within 30 days of being notified 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 collection agency for collections. In that event, the contingency fee assessed by the collection agency will be added to the principal and interest due. You will be additionally liable for attorney fees. Both collection agency fees and attorney fees will increase the balance you owe. Printed Name: Date of Birth: Signed: Date:

Patient Information. Today s date: Your Name: Social Security Number: Date of Birth: Age: Height: Weight: lbs. Street Address: City/State/Zip:

Patient Information. Today s date: Your Name: Social Security Number: Date of Birth: Age: Height: Weight: lbs. Street Address: City/State/Zip: Welcome to Randall Pain Management! 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