NAME: DATE OF BIRTH: GENDER:_ M F ADDRESS:_ CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE:_ DRIVERS LICENSE #:_

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Elmer Hopkins
5 years ago
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NEW PATIENT INTAKE NAME: GENDER:_ M F ADDRESS:_ CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE:_ SSN:_ DRIVERS LICENSE #:_ ETHNICITY: HISPANIC OR LATINO NOT HISPANIC OR LATINO PREFERRED

OCCUPATION:_ REFERRING PHYSICIAN: EDUCATION:_ PRIMARY CARE PHYSICIAN:_ OTHER PHYSICIANS:_ EMERGENCY CONTACT:_ EMERGENCY PHONE#: RESPONSIBLE PARTY INFORMATION NAME: ADDRESS:_ PHONE:_ SSN:

1 NEW PATIENT INTAKE NAME: GENDER:_ M F ADDRESS:_ CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK PHONE:_ SSN:_ DRIVERS LICENSE #:_ ETHNICITY: HISPANIC OR LATINO NOT HISPANIC OR LATINO PREFERRED LANGUAGE:_ RACE: AMERICAN INDIAN OR ALASKA NATIVE ASIAN BLACK OR AFRICAN AMERICA NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER WHITE RELGION:_ _ MARITAL STATUS:_ MARRIED_ WIDOWED SINGLE OCCUPATION:_ REFERRING PHYSICIAN: EDUCATION:_ PRIMARY CARE PHYSICIAN:_ OTHER PHYSICIANS:_ EMERGENCY CONTACT:_ EMERGENCY PHONE#: RESPONSIBLE PARTY INFORMATION NAME: ADDRESS:_ PHONE:_ SSN: RELATIONSHIP:_ EMPLOYER: EMPLOYER PHONE:_ EMPLOYER ADDRESS:_ INSURANCE INFORMATION INSURANCE COMPANY:_ INS. PHONE:_ INSURANCE ADDRESS:_ INSURED ID #:_ GROUP #: MEDICAID #:_ SECONDAY INS ID #:_ INSURED S NAME:_ INSURED S SSN:_ SECONDARY INSURANCE:_ SECONDAY INS GROUP #: RELATIONSHIP TO PATIENT: SELF -SPOUSE---DEPENDENT

2 INSURED S EMPLOYER:_ Clinic Policies Initials Payment is due at the time services are rendered. I understand that if I have insurance that I am the responsible party, and that having insurance does not guarantee payment of the services rendered to me. I authorize submission of my claim to the insurance company listed above. Initials If you are unable to make an appointment please call within 24 hours prior to your appointment time to reschedule. If you fail to notify our office prior to missing your scheduled appointment you will be charged a NO SHOW fee of $25 for an office visit and $50 for a procedure. Frequent NO SHOWS may result in a release from the practice. Initials Permission for treatment: I hereby authorize physician and assistants for the care of the patient named on this record to administer treatment as may be deemed necessary including examinations of treatments that may be ordered to be performed by the clinical personnel. I acknowledge that no guarantees have been made to me to the result of examinations or treatments to be performed. Acknowledgement of Review of Notice of Privacy Practices I have reviewed this office s notice of privacy practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. Signature of Patient or Representative Date Witness (CTPC Employee) Description of witness authority ***Please list the name of any person you wish to release your personal medical records/medical information to:

3 relationship:_ relationship: Even though we at GPW are committed to compassionate care, we must exercise proper due diligence when prescribing opioid analgesics for chronic pain. Prescription drug abuse has reached epidemic proportions in our society. Therefore, our clinic policy is that an appropriate workup must be completed prior to the dispensing of an opioid prescription. This workup will include review of previous pharmacy/clinic records, evaluation by diagnostic and laboratory tests, and acceptable completion of a urine drug screen yielding expected results. Common examples of opioid analgesics include hydrocodone, morphine, oxycodone, fentanyl, opana, and methadone. Prescriptions for these medications will not be given at an initial visit. Please bring your driver s license and insurance cards along with your completed new patient paperwork for your scheduled appointment. Payment for services are expected at the time of service (co-pays, co-insurance, private pay). We accept cash, money order, and credit cards (Visa, American Express, MasterCard, and Discover). If you have been instructed to obtain imaging reports and/or films by our staff, please bring them to your appointment. Your initial visit at GPW is a consultation. If a doctor referred you for an injection, you must be seen for an office visit. Procedures are scheduled after the initial consultation. If English is your second language, please make arrangements for someone to accompany you to your visit who can translate in order to provide you with the best healthcare service. We want you, to fully understand your diagnosis and prognosis, and have any questions you may have answered. We wish to make your visit as comfortable as possible, so please do not hesitate to contact us if you have any questions,

4 PAST MEDICAL HISTORY: Please indicate if you have suffered any of the following medical conditions. Also, state the year when these occurred. Pneumonia Depression Diabetes Kidney stones Gout Asthma Nervous breakdown Thyroid Kidney disease Emphysema High blood pressure Cancer Menopause Hormone problems Shingles Heart disease/attack Other blood abnormality PAST SURGICAL HISTORY Arthritis Herpes infection Insomnia Heart failure Stroke Headaches/migraines Gonorrhea Lupus Tuberculosis Seizures/convulsions Hepatitis Gall bladder Panic attacks Rheumatic heart Multiple sclerosis Syphillis Other venereal disease Prostate enlargement Irregular heart beats Chronic skin disease Jaundice AIDS or HIV Heart murmur Peptic ulcer disease Urinary infection Liver disease Fibromyalgia Schizophrenia/bipolar Peripheral vascular disease Other: FAMILY HISTORY: Please list any disease, illness, or ailments in your IMMEDIATE FAMILY (i.e. mother-breast cancer, father- diabetic, grandfather-heart disease). _ SOCIAL HISTORY Occupation:

5 Do you smoke? YES NO HOW MANY PACK/DAY? YEARS?_ Drink alcohol? YES NO IF YES HOW MUCH? Do you use any other drug(marijuana, Cocaine, etc)? YES NO Marital status? SINGLE MARRIED DIVORCED WIDOWED Do you live alone? YES NO IF NO WHO DO YOU LIVE WITH? ALLERGIES Latex: YES NO Adhesive: YES NO Betadine: YES NO Injection Dye: YES NO Steroids: YES NO Lidocaine/Marcaine: YES NO CURRENT MEDICATIONS REVIEW OF SYSTEMS In the past few months, have you had any of the following smptoms or difficulties? If you have any difficulty that bears further explanation, please indicate so and explain at the bottom of this page. GENERAL: Loss of appetite YES Fever or chills. YES NO NO Recent weight loss.. YES Low energy/fatigue YES NO NO EYES: Blurred vision YES NO Double vision... YES NO Loss of vision YES NO Eye Pain... YES NO HEAD/EARS/NOSE/THROAT: Hoarseness YES NO Hearing loss... YES NO Trouble swallowing.. YES NO Ear pain... YES NO CARDIOVASCULAR:

6 Chest pain.. YES NO Palpitations.... YES NO Leg Swelling.. YES NO Orthopnea... YES NO Varicose Veins.. YES NO RESPIRATORY: Shortness of breath... YES NO Chronic cough... YES NO Wheezing.... YES NO GASTROINTESTINAL: Nausea or vomiting... YES NO Heartburn.... YES NO Blood in stool.. YES NO Constipation.... YES NO Change in bowel habits.... YES NO Hemorrhoids... YES NO KIDNEY/BLADDER/URINE: Painful urination.. YES NO Blood in urine..... YES NO Frequent Urination..... YES NO Change in urinary pattern. YES NO MUSCULOSKELETAL: Significant pain/stiffness.. YES NO SKIN: Rash. YES NO Itching... YES NO Frequent Rashes... YES NO NEUROLOGICAL Tremor.. YES NO Dizziness.... YES NO Seizures... YES NO Tingling.. YES NO PSYCHIATRIC: Depression... YES NO Suicidal Thoughts... YES NO Drug/Alcohol addiction.. YES NO Trouble sleeping(insomnia).... YES NO Difficulty with sexual activities.. YES NO ENDOCRINE: Thyroid disease... YES NO Heat/Cold intolerance.. YES NO HEMATOLOGICAL/LYMPHATIC: Easy bruising... YES NO Easy bleeding.. YES NO IMMUNOLOGIC: Enlarged/.swollen lymph glands.. YES NO ADDITIONAL NOTES Is there an ongoing lawsuit related to your visit today? YES NO Are you currently under worker s compensation? YES NO

7 Location of your pain: When did it start: What happened and when?(car accident, fall, nothing, etc) Is your pain constant or comes and goes? From scale of 0 to 10 (0=no pain and 10= severe pain) how bad is your pain today? over the past 30 days what was your average pain score? Where does your pain start? Where does it go? Quality of your pain(circle all that apply) Numbness Pins & Needles Burning Aching Stabbing Shooting What aggravates your pain? (Circle all that apply) Sitting Bending Walking Lying down Leaning forward Leaning Back Coughing/sneezing Climbing upstairs Going downstairs What makes your pain better? (Circle all that apply) Sitting Bending Walking Lying down Leaning Forward Leaning Back Stretching Rest Heat Cold Medication If medication, which ones? What treatments have you tried? (Circle all that apply) Physical Therapy Chiropractor TENS Injections Massage Therapy Ibuprofen/Aleve/Motrin Over the counter ointments (Ben-gay, Icy-Hot, Myoflex) Traction Braces Nerve Block Hypnosis Accupuncture Biofeedback Ice/Heat Narcotics Religious Counseling Psychological Counseling Surgery Any of the above treatments help? If so which one?

If surgery, indicate how many, what kind, when, and if it helped: Which treatment helped you the most:_ Numbness Pins & Needles Burning Aching Stabbing ---------------- o o o o o o o o ^ ^ ^ ^ ^ ^ X

8 If surgery, indicate how many, what kind, when, and if it helped: Which treatment helped you the most:_ Numbness Pins & Needles Burning Aching Stabbing o o o o o o o o ^ ^ ^ ^ ^ ^ X X X X X X X Φ Φ Φ Φ Φ Φ Constant Intermittent Deep Superficial ccccccccc iiiiiiiiiiiiiiiiiiiiiii ddddd sssssssssss Using the appropriate symbol, mark the area(s) on your body where you feel each of the sensations above.

9 Beck Inventory Choose the one statement, from among the group of four statements in each question that best describes how you have been feeling during the past few days. Circle the number beside your choice. 1 0 I do not feel sad. 1 I feel sad. 2 I am sad all the time and I can t snap out of it. 3 I am so sad or unhappy that I cannot stand it. 2 0 I am not particularly discouraged about the future. 1 I feel discouraged about the future. 2 I feel I have nothing to look forward to. 3 I feel that the future is hopeless and that things cannot improve. 3 0 I do not feel like a failure. 1 I feel I have failed more than the average person. 2 As I look back on my life, all I can see is a lot of failure. 3 I feel I am a complete failure as a person. 4 0 I get as much satisfaction out of things as I used to. 1 I don t enjoy things the way I used to. 2 I don t get any real satisfaction out of anything anymore. 3 I am dissatisfied or bored with everything. 5 0 I don t feel particularly guilty. 1 I feel guilty a good part of the time. 2 I feel guilty most of the time. 3 I feel guilty all of the time. 6 0 I don t feel that I am being punished. 1 I feel I may be punished. 2 I expect to be punished. 3 I feel I am being punished. 7 0 I don t feel disappointed in myself. 1 I am disappointed in myself. 2 I am disgusted with myself. 3 I hate myself. 8 0 I don t feel I am worse than anybody else. 1 I am critical of myself for my weaknesses or mistakes. 2 I blame myself all the time for faults. 3 I blame myself for everything bad that happens. 9 0 I don t have any thoughts of killing myself. 1 I have thoughts of killing myself but I would not carry them out. 2 I would like to kill myself. 3 I would kill myself if I had the chance I don t cry any more than usual. 1 I cry more now than I used to. 2 I cry all the time now. 3 I would kill myself if I had the chance I am not more irritated by things than I ever am. 1 I am slightly more irritated now than usual. 2 I am quite annoyed or irritated a good deal of the time. 3 I feel irritated all the time now I have not lost interest in other people. 1 I am less interested in other people than I used to be. 2 I have lost most of my interest in other people. 3 I have lost all my interest in other people I make decisions about as well as I ever could. 1 I put off making decisions more than I used to. 2 I have a greater difficulty in making decisions than before. 3 I can t make decisions at all anymore I don t feel I look any worse than I used to. 1 I am worried that I am looking old or unattractive. 2 I feel that there are permanent changes in my appearance that make me look unattractive. 3 I believe that I look ugly I can work about as well as before. 1 It takes an extra effort to get started at doing something. 2 I have to push myself very hard to do anything. 3 I can t do any work at all I can sleep as well as usual. 1 I don t sleep as well as I used to. 2 I wake up 1 2 hours earlier than usual and find it hard to get back to sleep. 3 I wake up several hours earlier than I used to and cannot get back to sleep.

10 17 0 I don t get more tired than usual. 1 I get tired more easily than I used to. 2 I get tired from doing almost anything. 3 I am too tired to do anything My appetite is no worse than usual. 1 My appetite is not as good as it used to be. 2 My appetite is much worse now. 3 I have no appetite at all anymore I haven t lost much weight, if any, lately. (I am trying to lose weight? 1 I have lost more than five pounds. 2 I have lost more than ten pounds. 3 I have lost more than fifteen pounds trying to lose weight I am no more worried about my health than usual. 1 I am worried about my physical problems such as aches and pains or upset stomach. 2 I am very worried about physical problems and it s hard to think of much else. 3 I am so worried about my physical problems that I cannot think about anything else I have not noticed any recent change in my interest in sex. 1 I am less interested in sex. 2 I am much less interested in sex. 3 I have lost interest in sex completely.

Important Information About Your Visit

7121 Stephanie Lane, Suite 102 Lincoln, NE 68516 Phone: 402.413.5010 Fax: 402.413.5009 Web: innovativepainlincoln.com Important Information About Your Visit Even though we at Innovative Pain and Spine