Application For Admission Allied Health Group DRX Severe Back/Neck Pain Solution Program

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Application For Admission Allied Health Group DRX Severe Back/Neck Pain Solution Program If you are reading this you have been fortunate enough to qualify for a consultation with Dr. Dickhut at no charge. This however does NOT mean that your case has been accepted. Your consultation today will determine if A) You are a legitimate candidate for this program and B) Your condition is serious enough to warrant your case being accepted for treatment. In the event your condition IS serious enough to warrant being considered for acceptance and Dr. Dickhut is UNAVAILABLE to treat you, your case will be referred to another clinic. Today's Date Name Age Birthday Sex M F Address City State Zip Home Phone Work Phone Cell Phone E-Mail Address Best Place To Reach You (circle one) Home / Work / Cell May we leave a voice mail message for you? Yes No Employer Occupation Length of Employ SS# - - Marital Status S M W D Spouses Name I (signature) consent to allow Dr. Dickhut to speak with me and perform an examination (if necessary) in order to determine if I am a good candidate for non-surgical spinal decompression and also to determine if he is willing to accept my case. How Did You Hear About Allied Health Group? How Serious Do You Think Your Problem Is? What Is Your Main Problem/Symptom Prompting Your Request For A Consultation With The Doctor? Would You Consider This Problem (circle one)... MINIMAL (Annoying but causing NO limitations) SLIGHT (Tolerable but causing a little limitation) MODERATE (Sometimes tolerable but definitely causing limitations) SEVERE (Causing Significant limitations) EXTREME (Causing near constant (>80% of the time) limitations) Are you willing to pay for a part of the cost of care out of pocket? (Circle) YES or No On a scale of 1-10 (with 10 being the highest) how motivated are you to get rid of this problem? 1. In spite of the fact that you are not a back specialist, you are in fact the person who knows more about your back than anyone else. In your own words and in your own opinion what do you think the real problem is? 2. What are you hoping happens today as a result of your consultation with the Doctor? ---- 3. Since your back pain became this severe what three things has it caused you to miss the most?

4. How long have you been like this? ---- 5. Is there a particular activity or event that you believe caused and/or worsened your pain? ---- 6. How has your life changed since your back became a problem? 7. What activities are you limited in? ---- -- 8. What kinds of treatments have you received? Epidural: How Many Physical Therapy: How Long Medication: Surgery: Type Other When (approx) 9. Are you currently receiving any treatments for your pain? ---- 10. Did any of these treatments work? If so which one(s)? For how long? 11. Is there anything you can do that makes it feel better? ---- 12. What activities/movements are guaranteed to make it worse? ---- 13. Please describe the feeling of the pain. (Sharp, Dull, achy, toothache, shooting, stabbing, numb, tingling, etc...) 14. Is it worse in the morning or is it worse as the day progresses?

15. If you cannot find a solution to this problem what do you think will happen to you? 16. What are you hoping Dr. Dickhut tells you today? ---- 17. Describe what you hope or think he might be able to do for you. 18. Describe what will be different in your life if you can get better. List In Order Of Importance all OTHER Health Problems/Concerns NOT including Your Main Problem Above. 1. How Long Have You Had This? 2. How Long Have You Had This? 3. How Long Have You Had This? 4. How Long Have You Had This? In Reference To Your MAIN PROBLEM How Often Are You Aware of This Problem? (circle one) Occasionally (25% of the time) Intermittently (50% of the time) Frequently (75% of the time) Constant (90-100% of the time) Due To Your Main Problem... Have You Lost Any Time From Work? Yes No Have You Lost Any Time From Your Chores/Tasks At Home? Yes No Have You Lost Any Time From Your Family? Yes No Have You Lost Any Time From Your Leisure Activities? (Hobbies, Travel, Sports, etc...) Considering the amount of pain/discomfort you've had THIS week, how long has your problem been this severe? On a Scale of 0-10 (10 being unbearable, 0 being No Pain or Discomfort) Please rate the following... The HIGHEST your pain gets WITHOUT medication The LOWEST your pain gets WITHOUT medication The HIGHEST your pain gets WITH medication The LOWEST your pain gets WITH medication List ANY surgeries that you have had and the corresponding dates.

Have you had ANY of the following currently or in the last 12 months? (Mark C for Current. Mark X for last 12 mos. Leave blank if no symptoms in last 12 months.) GENERAL Chills Convulsions Diziness Fainting Fatigue Fever Headache Loss of Sleep Allergy (to what ) Loss of Weight Nervousness Wheezing Bronchitis Numbness in BOTH hands AND feet CARDIOVASCULAR High Blood Pressure Low Blood Pressure Pain over heart Poor Circulation Rapid Heartbeat Previous Heart Problem (Describe ) Slow Heartbeat Stroke TIA Swollen Ankles Varicose Veins Aortic Aneurysm Bruise Easily DISEASES/CONDITIONS Appendicitis Anemia Arthritis Alcoholism Abdominal Surgery Bleeding Disorder Blood Clot(s) Breathing Difficulty Cancer Cholesterol High Colon Problems Diabetes Depression Epilepsy Eczema Eating Disorder Glaucoma HIV + Heart Disease Hernia Headaches Influenza Kidney Disease Liver Disease Low back Pain Mental Illness Measles Mumps Pleurisy Pneumonia Polio Prostate Problems HyperThyroid HypoThyroid Rectal Surgery EARS/EYES/NOSE/THROAT Asthma Crossed Eyes Double Vision Blurred Vision Difficulty Swallowing Deafness Hearing Loss Ear Pain Thyroid Problem Nose Bleeds Sinus Problems Sore Throats GASTRO-INTESTINAL Gas Colon Trouble Constipation Diarrhea Gallbladder Trouble Hemorrhoids Liver Trouble Nausea Stomach Ache Poor Appetite Poor Digestion Vomiting Vomiting Blood Rectal Bleeding Bloating GENITO-URINARY Blood in Urine Frequent Urination Inability to control urine Kidney Infection Painful Urination Prostate Trouble Painful Urination FOR MEN ONLY Lump in testicles Penis discharge FOR WOMEN ONLY Menstrual Cramps Excessive menstrual flow Hot Flashes Irregular Cycle Painful periods Birth Control Pills Abnormal Pap Smear MUSCLE/JOINT/BONE Backache Foot Trouble Pain Between Shoulders Painful Tailbone Stiff Neck Spinal Curvature Swollen Joints NEUROLOGIC Seizures Dizziness Hand Trembling Weakness Difficulty with speech Loss of memory Loss of coordination RESPIRATORY Chest Pain Chronic Cough Difficulty Breathing Coughing/Spitting Blood OFFICE USE ONLY: Pn. Loc.:

Patient Consent CONSENT FOR TREATMENT: I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures. I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of such physician(s). RELEASE OF INFORMATION: By signing this form, you are granting consent to Allied Health Group to use and disclose your protected health information for the purposes of treatment, payment and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practices before you sign this consent, and we encourage you to read it in full. Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by telephoning our office at 309.268.9000. You have a right to request us to restrict how we use and disclose your protected health information for the purposes of treatment, payment or health care operations. We are not required by law to grant your request. However, if we do decide to grant your request, we are bound by our agreement. You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent. MEDICARE AND MEDICAID CONSENT TO RELEASE INFORMATION: I certify that the information given by me in applying for payment under Title XVIII and /or Title XI of the Social Security Act is correct. I authorize any holder of medical or other information about me, to release to the Social Security Administration or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim. VERIFICATION OF NON-PREGNANCY (Female Patients Only): By my signature on this form I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy suspected or confirmed at this particular time. Date of last menstrual period. Print Patient s Name Patient s Signature Other Than Patient, Print Name & Relationship Witness

Allied Health Group, Ltd. 1603 Visa Dr. #3 Normal, IL 61761 Phone: 309.268.9000 Fax: 309.268.9003 info@thespinedoctor.net NOTICE OF INFORMATION PRACTICES Protecting the privacy of your personal health information is important to us. This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purpose of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on disclosures. Disclosures of protected health information are limited to the minimum necessary for the purpose of the disclosure. This provision does not apply to the transfer of medical records for treatment. You may inspect and receive copies of your records within 30 days of submitting a request to do so. There may be a reasonable costbased fee for photocopying, postage, and preparation. You may request changes to your records. Our practice has the right to accept or deny your request. We maintain a history of protected health information disclosures that is accessible to you. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. Our practice is required to abide by this notice. We have the right to change this notice in the future. Any revisions will be prominently displayed in a clearly visible location in our office. You may file a complaint about privacy violations by contacting our Office Manager. Name Phone The effective date of this Notice of Information Practice is. Thank you.

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