Dr. Mark Valente Dr. Andy Indresano Board Certified, Fellowship Trained Phone. 972.707.0005 Fax. 888.992.6199 DISCspine.com New Patient Intake Form Name First MI Last Street Address Apt # _ City _ State Zip Date of Birth: / / Driver s License / _ Social Security # / / Month Day Year State Number Mobile Phone ( ) - Work Phone ( ) - Home Phone ( ) - E-mail address INSURANCE INFORMATION PRIMARY Insurance Company Address Insurance ID # _ Group # City State _ Zip Name of Insured _DOB / / Relationship to Insured Self Spouse Child Other Insured s Social Security # _ / _ / _ SECONDARY Insurance Company _ Address _ Insurance ID # _ Group # City State _ Zip Name of Insured: DOB / / Relationship to Insured Self Spouse Child Other Insured s Social Security # _ / _ / _ Employer Name _ Occupation Full Time Part Time Employer Address Employer Phone ( ) _- Marital Status Single Married Divorced Widowed Spouse s Name Spouse s DOB / / First MI Last Mo. Day Year Spouse s Social Security # / / Spouse s Employer Work Phone ( ) _-_ Emergency Contact Relationship Street Address Apt # _ City State _ Zip Home Phone ( ) _- Work Phone ( ) _- Mobile Phone ( ) _- Page 1 of 6 Patient Name Date of Birth //_ Today s Date //
REFERRAL INFORMATION How did you first hear of us? Internet search (google) Internet advertisement Facebook Insurance Physician North American Spine Magazine - which one? Direct Mailing TV Billboard Other Radio REFERRING PHYSICIAN Name of Physician who referred you to us: What city is their office in: Name of your Primary Care Physician (PCP): _ What city is their office in: CONSENT FOR TREATMENT FORM I understand that I have presented myself to Dr. Mark Valente and/or Dr. Andrew Indresano, Renaissance Neurodiagnostics, P.A. (d/b/a DISC Spine Institute), and/or DISC Clinic, PLLC for evaluation and/or treatment for my condition. I authorize and direct Dr. Valente and/or Dr. Indresano to perform quality care upon me, and understand that all options will be discussed prior to the administration of treatment. I acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as to the outcome of any procedures and/or treatments. I grant this consent without duress, confusion, or pressure from my physician and/or his or her staff, associates, or colleagues. FACSIMILE AUTHORIZATION FORM I, the undersigned, authorize Dr. Valente and/or Dr. Indresano (DISC Spine Institute/DISC Clinic) to send/receive confidential healthcare information as the term is defined by HIPAA (Health Insurance Portability and Accountability Act of 1996, 45 C.F.R., Parts 160-164) by facsimile to healthcare providers, hospitals, laboratories, and other medical caregivers in the necessary coordination of care for the patient listed below. I may revoke this authorization by giving Dr. Valente and/or Dr. Indresano (DISC Spine Institute/DISC Clinic) five (5) days written notice. This revocation may be by facsimile transmission, however, a written copy of the revocation must be mailed to Dr. Valente/Indresano as well. ASSIGNMENT OF BENEFITS / FINANCIAL AGREEMENT I hereby give authorization for payment of insurance benefits to be made directly to Dr. Valente and/or Dr. Indresano (DISC Spine Institute/DISC Clinic) and any assisting physicians, PA, NP, RNFA, or CRNA for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collection. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original. ACKNOWLEDGEMENT OF FINANCIAL INTERESTS I, the undersigned, acknowledge that Dr. Mark Valente and/or Dr. Andrew Indresano at any given time may be a consultant, owner, manager, director, or developer of various entities including but not limited to companies that develop, distribute, and/or manufacture spinal biologics and implants and may have financial interests in various physician owned entities including but not limited to: medical device distributorships/manufacturers, management companies, laboratories, pharmacies, neuromonitoring, imaging, first assist and/or anesthesia companies, ambulatory surgery centers and/or hospitals, that may pertain to your care. ACKNOWLEDGEMENT FORM I have received and/or reviewed the Notice of Privacy Practices. I have received a copy of the financial policy for this practice and agree to adhere to the terms. This release will remain in effect until revoked by me in writing. Patient Signature Date Witness Signature Date Page 2 of 6 Patient Name Date of Birth //_ Today s Date //
CONTACT AUTHORIZATION Check where you can be reached during business hours Home Work Mobile May we contact you at home? Yes No May we contact you at work? Yes No Leave message with Leave message with Voicemail / Answering Machine Yes No Voicemail / Answering Machine Yes No Mobile Phone Yes No Mobile Phone Yes No Family Member Yes No Co-worker Yes No I hereby give permission to the DISC Spine Institute/DISC Clinic to disclose and discuss any information related to my medical conditions to/with the following (relatives, or close personal friends) Name _ Relationship Name _ Relationship OR _ I do not wish to give permission for additional family members, relatives or close personal friends to have access to any information regarding my medical conditions. LEGAL GUARDIAN/ MEDICAL POWER OF ATTORNEY Name Relation Phone # Address Patient Signature Date _ A copy of ANY Power Of Attorney, full or medical, will be furnished to this office within 14 days of this appointment with a copy of the POA holder s identification card to be kept on file in your chart. Failure to do so will result in our office being unable to supply any information to your POA holder. PREFERRED PHARMACY Name: City: _ Phone Number: ( ) _- Page 3 of 6 Patient Name Date of Birth //_ Today s Date //
PAIN DIAGRAM Please mark the area of discomfort on the diagram below using the appropriate symbols Pain or burning x x x x x Numbness o o o o o Pins and Needles = = = = = Grade your overall pain Please place an X on the hash mark that most accurately describes your overall degree of pain now. HISTORY (Check all that apply) Your Age Chief Complaint Back pain Leg symptoms: Pain Numbness Weakness Neck pain Arm symptoms: Pain Numbness Weakness Is your condition the result of a Work injury? YES NO Auto accident? YES NO Was there a trauma or inciting incident? What is the date of the injury? Form 100.11a - Intake Form Page 4 of 6 Patient Name Date of Birth / / Today s Date / /
Symptoms have been present for How many years How many months How many weeks Symptoms are described as Sharp Dull Achy Burning Spasms My pain is Worsening Improving Same (unchanged since it started) For patients with primary neck and arm pain: Neck Pain _ % + Arm Pain % = 100% For example 70 + 30 = 100% If you have significant arm pain Left Arm Pain _ % + Right Arm Pain % = 100% Do you have difficulty picking up small objects like coins or buttoning buttons? YES NO Do you have problems with balance or frequent tripping? YES NO There is No loss of bowel or bladder control (incontinence) Loss of bowel and bladder control since: For patients with primary neck and arm symptoms - Have you had the following treatments for your neck? Anti-inflammatories Physical Therapy Facet injections Epidural steroid injections For patients with primary back and leg pain Back Pain _ % + Leg Pain % = 100% For example 70 + 30 = 100% If you have significant leg pain Left Leg Pain _ % + Right Leg Pain % = 100% Worst position for pain is Sitting Standing Walking How many minutes can you stand/walk before you need to rest? less than 5 min less than 30 min less than 60 min 60+ Sitting Makes the pain worse No change in pain Makes the pain better Bending forward Makes the pain worse No change in pain Makes the pain better Lying down Makes the pain worse No change in pain Makes the pain better I have Not missed any work because of this problem How much work have you missed _ Treatment has included Anti-inflammatory medication Muscle relaxants Narcotic pain medication Braces NO medication, physical therapy, chiropractic manipulations, injections, or bracing Traction Acupuncture Chiropractic manipulation Physical Therapy Trigger point injections Sacroiliac injections Facet injections Epidural Steroid Injections Other _ PAST MEDICAL HISTORY Check all that apply Osteoarthritis Rheumatoid Arthritis Ankylosing Spondylitis Bleeding disorders Blood clot in leg Blood clot in lung Lung disease None apply Liver disease Heart failure (CHF) Stroke HIV Hepatitis High blood pressure Seizures AIDS Thyroid trouble Diabetes Mental illness Tuberculosis Heart attack Kidney stones Asthma Anemia Kidney failure Serious injury (explain) Gout Cancer Osteoporosis Alcoholism Stomach ulcers Other Form 100.11a - Intake Form Page 5 of 6 Patient Name Date of Birth / / Today s Date / /
PAST SURGICAL HISTORY Type of Surgery Approx. Year Type of Surgery Approx. Year MEDICATIONS Please list ALL CURRENT medications and doses None ALLERGIES Please list any known allergies to food or medications and their reactions I have no known Drug/Medication Allergies REVIEW OF SYSTEMS Are you currently or have had problems with: Hematological / Bleeding problems * Please explain and describe all YES answers below Yes No Describe _ Unexplained weight loss Yes No Describe _ Skin Yes No Describe _ Ear, Nose, Throat Yes No Describe _ Stomach / Digestion Yes No Describe _ Bladder / Bowel problems Yes No Describe _ Musculoskeletal Yes No Describe _ Neurological Yes No Describe _ Psychiatric problems Yes No Describe _ Fever / Chills Yes No Describe _ Night sweats Yes No Describe _ Night pain / Pain at rest Yes No Describe _ FAMILY HISTORY Check all that apply None apply Stroke Alcoholism Kidney trouble or stones Seizures Bleeding disorders Arthritis Heart trouble Cancer Diabetes Other: Gout Mental illness High blood pressure Spine problems SOCIAL HISTORY Height Weight Occupation Work Status Homemaker Retired Disabled On leave Unemployed Employed: Full time Part time Marital Status Married Single Divorced Widowed Number of living children: None I live Alone With Do you smoke? Yes No packs/day for years Quit How long ago? _ Drink alcohol? Daily 1-2 x/week 1-2 x/month Never Alcoholic Recovering alcoholic Illicit drug use Never Currently In the past Patient Name Date of Birth / / Page 6 of 6 Today s Date / /