1 Patient Information : Name: Last First MI Email address: Mailing Address: Phone # (H) (W) (Other) Can we call you at work? Yes No of Birth: Can we leave messages on voice mail at home/work/cell? Yes No Sex: Male Female SS#: How did you hear about our practice? Emergency contact: Name: Relation: Phone #: Phone #: (H) (W) Accident Information Is this visit due to an accident? Yes No If yes, what type? Auto Work Other Has it been reported? Yes No If yes, to whom? Insurance Information Do you have health insurance? Yes No Name of Carrier: Name listed on Policy: D.O.B. : Relationship to patient (if other than self): Phone # Do you have secondary insurance? Yes No Name of Carrier: PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S) Assignment and Release (insured patients) I certify that I (or my dependent) have insurance coverage with and I AUTHORIZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PAIN RELIEF CENTER. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions. SIGNATURE (X) DATE Form 2
2 What is the reason for your visit today? Please circle below any areas that you are expierencing symptoms and provide a number rating your pain from 0-10: Knee Shoulder Feet/Legs Back Neck Headaches Hips Please circle or place a mark in the box below to indicate any areas that you are having pain or symptoms: 3. How often do you experience your symptoms? Constantly (76-100% of the time) Occasionally (26-50% of the time) Frequently (51-75% of the time) Intermittently (1-25% of the time) 4. How would you describe the type of pain? Sharp Numb Dull Tingly Diffuse Sharp with motion Achy Shooting with motion Burning Stabbing with motion Shooting Electric like with motion Stiff Other: 5. How are your symptoms changing with time? Getting Worse Staying the Same Getting Better 6. Using a scale from 0-10 (10 being the worst), how would you rate your problem? 0 1 2 3 4 5 6 7 8 9 10 (Please circle) 7. How much has the problem interfered with your work? Not at all A little bit Moderately Quite a bit Extremely 8. How much has the problem interfered with your social activities? Not at all A little bit Moderately Quite a bit Extremely 9. Who else have you seen for your problem? Chiropractor Neurologist Primary Care Physician ER physician Orthopedist Other: Massage Therapist Physical Therapist No one 10. How long have you had this problem? 11. How do you think your problem began?
12. Do you consider this problem to be severe? Yes Yes, at times No 3 When was is Diagnosed? 13. What aggravates your problem? 14. What concerns you the most about your problem; what does it prevent you from doing? 15. What is your: Height Weight 16. How would you rate your overall Health? Excellent Very Good Good Fair Poor 17. What type of exercise do you do? Strenuous Moderate Light None 18. Indicate if you have any immediate family members with any of the following: Rheumatoid Arthritis Diabetes Lupus Heart Problems Cancer ALS 19. For each of the conditions listed below, place a check in the "past" column if you have had the condition in the past. If you presently have a condition listed below, place a check in the "present" column. Past Present Past Present Past Present Headaches High Blood Pressure Diabetes Neck Pain Heart Attack Excessive Thirst Upper Back Pain Chest Pains Frequent Urination Mid Back Pain Stroke Smoking/Tobacco Use Low Back Pain Angina Drug/Alcohol Dependance Shoulder Pain Kidney Stones Elbow/Upper Arm Pain Kidney Disorders Depression Wrist Pain Bladder Infection Systemic Lupus Hand Pain Painful Urination Epilepsy Hip Pain Loss of Bladder Control Dermatitis/Eczema/Rash Upper Leg Pain Prostate Problems HIV/AIDS Knee Pain Abnormal Weight Gain/Loss Ankle/Foot Pain Loss of Appetite For Females Only Jaw Pain Abdominal Pain Birth Control Pills Joint Pain/Stiffness Ulcer Hormonal Replacement Arthritis Hepatitis Pregnancy Rheumatoid Arthritis Liver/Gall Bladder Disorder Cancer General Fatigue Tumor Muscular Incoordination Asthma Visual Disturbances Chronic Sinusitis Dizziness Other: Any food or medication allergies? 20. List all prescription medications you are currently taking: 21. List all of the over-the-counter medications you are currently taking: 22. List all surgical procedures you have had: 23. What activities do you do at work? Sit: Most of the day Half the day A little of the day Stand: Most of the day Half the day A little of the day Computer work: Most of the day Half the day A little of the day On the phone: Most of the day Half of the day A little of the day 24. What activities do you do outside of work? 25. Have you ever been hospitalized? No Yes if yes, why 26. Have you had significant past trauma? No Yes
NEUROLOGICAL/ MRI/ VASCULAR PATIENT QUESTIONNAIRE 4 For any YES answer, please include details. 1. Do you suffer from neck pain with or without pain in your shoulder, arms or hands? NO YES 2. Do you have weakness, numbness or burning in your shoulder, arms or hands? NO YES 3. Do your hands or arms fall asleep regularly? NO YES 4. Do you have reduced feeling (sensation) or swelling in your hands or arms? NO YES 5. Do you suffer from a loss of handgrip strength? NO YES 6. Do you suffer from back pain with or without pain in your buttocks, legs or feet? NO YES 7. Do you have weakness, numbness or burning in your buttocks, legs or feet? NO YES 8. Do our legs or feet fall asleep regularly? NO YES 9. Do you have reduced feeling (sensation) or swelling in your legs, feet? NO YES 10. Do you suffer from cold hands or feet? NO YES 11. Do have frequent falls or find that you trip over your feet while walking? NO YES 12. Do you suffer from frequent headaches? If yes, how often? NO YES Informed Consent to Care I agree to grant permission to the doctor or designated medical provider to perform examinations and in accordance with appropriate tests, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render a patient susceptible for injury. The medical provider, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through other health care providers and diagnostic test from whatever other conditions he/she is suffering from such as but not limited to: latent pathological defects, illnesses, or deformities, which would otherwise be know by our medical staff. I agree to inform the medical provider of any known conditions or medical illness that may pose a risk to my health. I agree to settle any claim or dispute I may against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request. Patient s Signature
5 X-ray Questionnaire: For women only Our consultation and examination may indicate that x-rays are necessary to accurately diagnose and analyze your condition. Should x-rays be necessary we would like to confirm that you are not pregnant at this time. Name: There is a possibility that I a may be pregnant at this time. Yes, I am definitely pregnant No, I am definitely not pregnant at this time I request that x-ray films not be taken becaus of last menstrual period: Patient s Signature ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I have been offered a copy of the Notice of Privacy Practices of The Pain Relief Center. (Please initial one of the following options and sign below.) I wish to receive a paper copy of Privacy Notice. I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and the Privacy Notice is posted in the office. Please initial below: I allow the Pain Relief Center to leave reminder messages on my answering machine or with another person in my home. I may make a request of an alternative means of communication (within reason) in writing. Signature of Patient/Guardian Witness (Office Staff)
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