NEW PATIENT HEALTH HISTORY AND PAIN QUESTIONNAIRE
Patient Name: _____________________________________Age ______ Male
Female
Right handed
Left handed
Ambidextrous
History of Problem for which you are being seen: Reason for visit: _____________________________________________________________ By whom were you referred to our practice?_________________________________________ Expectations from treatment:___________________________________________________ Type of injury: Car accident:
Job Accident Driver
Sports Injury
Passenger
Other: _________________
Seat-belted:
Yes
No
Airbag:
Yes
No
Date injury/symptoms started: _____________________________________________________ Do you have cancer?
Yes
No
Cancer Type/Stage: __________________________________
How would you describe your mood in a word or two? ________________________________ On the diagram below, shade the areas where you feel pain. Put an “x” where it hurts the most; check all terms that apply. Aching Burning Stabbing Shooting Constant Transient Sharp Dull Mild Moderate
R
L
L
R
Severe Unbearable Numbness Tingling Rate your pain by circling the one number that best describes your pain at its worst: 0 1 2 3 4 5 6 7 8 9 10 No Pain Pain worst imaginable Rate your pain by circling the one number that best describes your pain at its least: 0 1 2 3 4 5 6 7 8 9 10 No Pain Pain worst imaginable Rate your pain by circling the one number that best describes your pain on the average: 0
1
2
3
4
5
6
No Pain
7
8
9
10 Pain worst imaginable
Page 1 of 5
What makes pain worse: __________________________________________________________ What makes pain better: _________________________________________________________ Time of the day when pain is worse:___________________________________ Do you have the following?: Weakness in your: arms right left legs Numbness in your: arms right left legs New or recurrent problems with bowel or bladder control? Yes Change in pain with cough/sneeze/bowel movements? Yes
right right no no
left left
Medication History Indicate what you have used for your current pain condition: If you have tried any of the listed medications, please indicate whether it helped with your pain or not by checking the appropriate box. If you have not tried an agent, check “never tried”
Narcotics/Opiates: Did it help? Yes/No Never tried Butrans Patch Codeine (Tylenol #3) Fentanyl Patch (Duragesic) Hydrocodone (Vicodin, Norco) Hydromorphone (Dilaudid,Exalgo) Morphine (Kadian, MS Contin) Methadone Nucynta Oxycodone (Oxycontin) Oxymorphone (Opana) Tramadol (Ultram) Other/Comments:_________________________________________________________________ Antiinflammatories: Did it help? Yes/No Never tried Aspirin Celebrex (Celecoxib) Diclofenac (Voltaren) Etodolac (Lodine) Ibuprofen (Motrin, Advil) Indomethacin Meloxicam (Mobic) Naproxen (Aleve, Naprosyn) Nabumetone (Relafen) Tylenol Other/Comments:_________________________________________________________________ Antineuropathics: Did it help? Yes/No Never tried Amitriptyline Duloxetine (Cymbalta) Gabapentin (Neurontin) Milnacipran (Savella) Nortriptyline Pregabalin (Lyrica) Topiramate (Topamax) Other/Comments:_________________________________________________________________ Muscle Relaxants: Did it help? Yes/No Never tried Baclofen Carisoprodol (Soma) Chlorzoxazone (Lorzone) Cyclobenzaprine (Flexeril) Metaxalone (Skelaxin) Methocarbamol (Robaxin) Tizanidine (Zanaflex) Other/Comments:_________________________________________________________________ Page 2 of 5
TREATMENT HISTORY: If you have tried any of the listed treatments, please indicate whether it helped with your pain or not by checking the appropriate box. If you have not tried an agent, check “never tried”
Treatment: Did it help? Yes/No Never tried Physical Therapy Chiropractic TENS Unit Acupuncture Trigger Point injections Joint injections Facet block/Medial Branch Block Epidural Steroid Injection Radiofrequency Ablation Spinal Cord Stimulator Psychiatric/Psychological care Other/Comments:_________________________________________________________________ Name of prior Pain Physician(s): _____________________________________________ Are you currently taking Anticoagulants/Blood Thinners? If yes, what type? Warfarin/Coumadin Plavix (Clopidogrel) Pradaxa
Aspirin Eliquis Arixta
Yes/No
Lovenox Other________________ Heparin Herbals (Garlic, Ginko, Ginseng, Vitamin E)
Why are you taking a blood thinner?___________________________________________________
Diagnostic Studies: X-Ray CT Scans EMG/NCS
Yes Yes Yes
No No No
MRI Scan Yes No Bone Scan Yes No Other _____________
Past Medical History: Cardiac High Blood Pressure Coronary Artery Disease Pacemaker /AICD Pulmonary COPD Sleep Apnea Renal Dialysis
Congestive Heart Failure Irregular Heartbeat Blood Thinners
Heart Attack Heart Murmur Valvular Disease
Angina/Chest Pain Cardiac Stents Vascular Disease
Emphysema Bronchial Disease
Asthma Tobacco
Lung Cancer
Renal Insufficiency
Kidney Stone
Prostate Problems
Seizures
Nerve Damage
Neurological Stroke
Transient Ischemic Attack
Infectious Valley Fever
Tuberculosis
HIV/AIDS
Polio
Hepatic Liver Disease
Cirrhosis
Hepatitis
Gall Bladder
If you have Hepatitis, please specify what type (if known):_____________________________ Gastrointestinal Hiatal Hernia
GERD
Gastric Ulcers Page 3 of 5
Colitis
Endocrine Thyroid Disease
Parathyroid Disease
Diabetes Mellitus
Psychological Depression
Bipolar
Addiction
Schizophrenia
General Anemia/Bleeding
Arthritis
Obesity
Alcoholism
Past Surgical History (be as specific as possible, including surgery type and year of surgery): 1. _________________________2.______________________3._______________________ 4. _________________________5.______________________6._______________________
Serious Injury: List serious injuries you have sustained: _______________________________________________
Allergies to Medications:
Yes
No (if yes, indicate below drug and reaction)
Drug _________________________
Reaction ___________________________
_________________________
___________________________
_________________________
___________________________
Current Medications (Include vitamins, antacids, birth control, etc., attach list if necessary): Name: 1. ______________________
Dose: ______________________
How often: ________________
2. ______________________
______________________
________________
3. ______________________
______________________
________________
4. ______________________
______________________
________________
5. ______________________
______________________
________________
6. ______________________
______________________
________________
Family History: __________________________________________________________ Is there any history of drug/alcohol abuse/addiction in your family?
Yes
Social History: Occupation: _______________________________________________________ Are you currently working? Yes No Part-time Full-time Education: Elementary High school College Graduate school Marital Status: Married Widowed Divorced Single Significant Other Children: Y/N If yes, how many? _________ Do you have any lawsuits pending or planned? Yes No Are you on disability? Yes No Workmen’s Comp? Yes No Tobacco use: Current Former Never If current: #of packs per day __________ How many years? ________ Alcohol: Do you consume alcohol? Yes No If Yes: Approximate #of drinks per day _________ How many years?________ Illicit/Street Drugs: Do you use any illicit/street drugs? Current Former Never If current/former: What drugs?_________________________________________ Have you ever been in treatment for drug or alcohol problems? Yes No Do you currently use Medical Marijuana? Yes No
Page 4 of 5
No
Review of Systems (List only current or very recent symptoms): General:
Weight Change Fever No Problems
Fatigue Loss of Appetite
Weakness Chills
Cardiac:
Chest pain/Angina Peripheral Edema
Shortness of Breath No problems
Palpitations
Endocrine: urination
Heat intolerance
Excessive sweating
Excessive
Cold intolerance
Excessive thirst
No problems
Gastrointestinal:
Diarrhea Change in appetite Loss of bowel control No Problems
Reflux Abdominal pain Blood or Black Stool
Constipation Nausea Vomiting
Genitourinary:
Difficulty Urinating Loss of Bladder Control
Painful Urination No Problems
Blood in urine
HEENT:
Sinus Problems Jaw Problems Mouth Problems
Difficulty Swallowing Dry Mouth No Problems
Headache Migraines
Hematology/ Oncology:
Chemotherapy History Radiation History
Bleeding Disorder Anticoagulation Therapy
No Problems
Musculoskeletal:
Muscle Cramps Joint Redness Joint Heat
Joint Stiffness Joint Swelling
Muscle atrophy No Problems
Neurological:
Blackouts Fainting Hallucinations Tremors
Weakness Paralysis Dizziness Confusion
Numbness Gait Difficulties No Problems
Opthalmology:
Blurred Vision Double Vision
Eye Pain No Problems Photophobia (light is painful)
Psychiatric:
Depression Drug Abuse
Suicidal Ideation Homicidal Ideation
Anxiety No Problems
Respiratory:
Cough Hemoptysis
Shortness of Breath No Problems
Wheezing
Skin:
Dry Skin Changes in Skin Color Itching
Changes in Hair or Nail Recurrent Rashes
Eczema No Problems
Toxins:
Asbestos Pesticides
Industrial Chemicals Drug Use
Lead No Problems
___________________________________ Patient Signature
_____/_____/_____ Date
Reviewed by: _________________________ Provider Signature
_____/_____/_____ Date
Page 5 of 5
PATIENT REGISTRATION FORM Date_________________ Patient’s Name__________________________________________________________________________________ Address________________________________________________________________________________________ City _______________________State ________Zip Code____________ email ______________________________ Home Phone (___) _______________ Mobile (___) __________________ Work Phone (___) __________________ Social Security #___________________________ Date of Birth______________ Sex _____Marital Status_________ Referring Physician__________________________________________________Phone_______________________ Primary Care Physician_______________________________________________Phone_______________________ Patient’s Employer _______________________________________________________________________________ Employer Address________________________________________________________________________________ Responsible Party Information
Self _____
Spouse _____ Parent ______ Other ______
Guarantor’s Name________________________________________________________________________________ Address________________________________________________________________________________________ City _______________________State ________Zip Code____________ Home Phone (___) _______________ Mobile (___) __________________ Work Phone (___) __________________ Relationship to Patient _______________Date of Birth _______________Social Security #______________________ Guarantor’s Employer ____________________________________Work Phone (______) _______________________ Employer Address_______________________________________________________________________________ Emergency Contact Information Name______________________________________________________________Relationship__________________ Address________________________________________________________________________________________ Home Phone (___) _______________ Mobile (___) __________________ Work Phone (___) __________________ Insurance Information Primary Carrier:
Name ______________________________________________Group #_____________________________ Address__________________________________________________________________________ Policy Holder’s Name _________________________________Relationship to Patient__________________ Policy Holder's Date of Birth______________________ Social Security #_______________________ Policy #_____________________________________
Secondary Carrier:
Name ____________________________________________Group #_______________________________ Address_________________________________________________________________________________ Policy Holder's Name __________________________________Relationship to Patient_________________ Policy #______________________________________ Policy Holder’s Date of Birth____________________
Workmen’s Comp:
Carrier__________________________________________________________________________________ Address_________________________________________________________________________________ Date of Injury __________________________________Claim #___________________________________ Claim Representative _____________________________Phone (______) ____________________________ Employer________________________________________________________________________________
PATIENT DEMOGRAPHICS In order to participate in federal and state healthcare programs, our practice requests the demographic information below. The terms below are the federal government's standards for classification of race and ethnicity.
Race (please check one box) American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American. A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. More than one race I prefer to not provide this information
Ethnicity (please check one box) Hispanic or Latino Not Hispanic or Latino Undefined I prefer to not provide this information
Preferred Language (please check one box) Spanish English Other (please list) _________________ I prefer to not provide this information
AUTHORIZATION AND RELEASE I authorize the release of any Protected Health Information including the diagnosis and the records of any treatment rendered to my child or me during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to Valley Pain Consultants insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of services rendered on my behalf or my dependents. ______________________________________ Signature of Patient or Parent, if a minor
Date: _______________________
______________________________________ Printed Name of Patient / Minor
CONSENT TO RELEASE INFORMATION TO FAMILY I hereby give my consent to release Protected Health Information from my medical and/ or financial records from Valley Pain Consultants to whomever requests it and identifies themselves as an immediate family member, including spouse, sibling, children, grandchildren, and anyone specifically listed below. ________________________________
____________________________
I specifically DENY permission to release information to anyone without my written consent. ______________________________________ Signature of Patient or Parent, if a minor Printed name of Patient/ Minor
________________________ Date
______________________________________ Printed name of Patient/Minor
CONSENT TO RELEASE INFORMATION TO PHYSICIAN I hereby give consent to release Protected Health Information regarding my treatment and/or copies of my medical record to my referring physician and/or primary care physician as listed on the Patient Registration Sheet. ___________________________________________ Signature of Patient or Parent, if a minor
_________________________ Date
_______________________________________ Printed Name of Patient/ Minor
CONSENT TO TREAT I further authorize and consent to the Practice’s physicians and their assistants and other Practice professional staff providing outpatient medical treatment, supplies, services, equipment and other items related to my healthcare to me as determined to be necessary in their professional judgment. I have been informed of the nature and purpose of the treatment, and potential common side effects thereof, as well as alternative treatment modalities, the approximate estimated duration of my healthcare, and that I am able to withdraw my consent for treatment either orally or in writing whether prior to or during the anticipated treatment period. ________________________________________ Signature of Patient or Parent, if a minor ________________________________________ Printed Name of Patient/Minor
_____________________________ Date
I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. Valley’s Notice of Privacy Practices explains the process for revocation, which includes a request in writing. Unless I revoke this authorization earlier, this Consent for Release of Protected Health Information will remain in effect until terminated by me in writing.
Dear Patient _________________________, Due to all of the various HMO and PPO insurance plans now available in the marketplace, it has become a very complicated process to become familiar with each plan. All of the various companies and plans have their individual requirements for various procedures. It has therefore become necessary to request that all patients provide all information needed from their insurance company, and that they assume responsibility for providiing this information to our office, and to any other health facility involved in their particular treatment or illness, including hospitals. Patients must also notify their insurance company of any changes in their care or treatment so that proper handling and payment will be made by their insurance company. You may receive a pre-certification or authorization number from your insurance company. Please remember that this does not guarantee that your insurance company will pay for the procedure. It is your responsibility to call your insurance benefits department to see if you have any pre-existing or routine testing clauses in your contract which would prevent your insurance company from paying the bill. We have always filed and will continue to file claims for patients, but you must share equal responsibility for obtaining and giving the doctor or insurance company the necessary information needed to get your claim processed and paid within a reasonable time period. We realize that patients are not always given all the information required by their insurance company or agent, but it is still your responsibility to call and obtain this information before receiving treatment and before filing claims for treatment. We cannot emphasize enough how important this is, in order for you to receive the proper benefit you are entitled to under your insurance plan or contract. We are requesting your cooperation so that we may better serve you and give you the health care you deserve, without having to spend an exorbitant amount of time dealing with your insurance company. You should have and know all the information required by your individual plan(s) of insurance to avoid any confusion on your behalf of what services are covered by your insurance policie(s). Thank you for your cooperation.
_____________________________________________ Patient Signature or Parent of Minor
______________ Date
CONSENT FOR THE USE OR RELEASE OF PROTECTED HEALTH INFORMATION FOR TREATMENT PAYMENT OF HEALTHCARE OPERATIONS As set forth more fully in our Notice of Privacy Practices, we are permitted to obtain your consent for any use or disclosure of your health information to carry out treatment, payment, or health care operations. In our Notice of Privacy Practices, we provide you information about how this office can use or disclose your health information. You have a right to review our Notice of Privacy Practices before signing this Consent. The Notice is available on our website or a brochure can be obtained at the front desk. We reserve the right to change the terms of our Notice of Privacy Practices at any time. If you have any questions related to the notice, you may contact Valley’s Privacy Officer, Dean F. Smith III, MD, or Patricia Durlam, RN, MAOM, Practice Administrator at 1850 N. Central Avenue, Suite 1600, Phoenix, AZ 85004 (telephone: 602.262.8903). By signing this form below, you consent to our use and disclosure of your health information for treatment, payment or health care operations. You have the right to request that we restrict how your health information is used or disclosed to carry out treatment, payment or health care operations. We are not required to agree with your requested restrictions; however, if we do agree to your restrictions, we are bound to follow them. I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. Valley’s Notice of Privacy Practices explains the process for revocation, which includes a request in writing. Unless I revoke this authorization earlier, this Consent for Release of Protected Health Information will remain in effect until terminated by me in writing. I understand that information in my health record may include information relating to Sexually Transmitted Disease, Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) and other communicable diseases, Behavioral Health Care/Psychiatric Care, treatment of alcohol and/or drug abuse. My signature authorizes release of information as it pertains to authorization or billing needs. ________________________________ Signature of Patient or Legal Representative
_____________ Date
If signed by Legal Representative, please describe the authority of Legal Representative to sign for patient: _______________________________
o
I have received a copy of the Notice of Privacy Practices
Yes __
No __ Initials ___
o
I have declined a copy of the Notice of Privacy Practices
Yes __
No __ Initials ___
EXPECTATIONS OF PATIENT/CAREGIVER The following statements are expectations that we as a practice would like you to be informed. Once signed, you as a patient/caregiver acknowledge understanding of these policies and are aware that any violation of these policies may result in discharge from our practice. I_________________ understand that the medications I may receive from this practice are provided for their therapeutic value; however, they may have serious side effects. These side effects may be accentuated by the concurrent use of other medications and/or alcohol. It is unsafe to combine any medications and/or alcohol without first consulting with my physician. I also understand that I will need to take steps to prevent any pregnancy while on these medications due to the potential impact on the fetus. I understand that any medication that I receive from this practice may affect my ability to operate a motor vehicle, boat, or heavy machinery. I am accountable for determining whether my ability to do these things is impaired. I will be solely accountable for my decision regarding this as outlined under Arizona State Law, Title 28, Chapter 4, Article 3: “It is unlawful for a person to drive or be in actual physical control of a vehicle in this state under the influence of intoxicating liquor, and drug, a vapor releasing substance containing a toxin or any combination of liquor, drugs, or vapor releasing substances if the person is impaired to the slightest.” In Arizona, this may be grounds for prosecution of a Driving While Intoxicated (DWI)offense.________ initials) I am expected to be respectful of the physicians and staff, and I understand that inappropriate behavior will not be tolerated and may result in my dismissal from the Valley Pain Consultants practice.
Patient Signature__________________________ Date ______________
DIRECT FINANCIAL INTEREST DISCLOSURE STATEMENT
State law, A.R.S. 32-1401 (25)(ff), requires that a physician notify a patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient and/or in the non-routine goods or services being prescribed by the physician, and whether these are available elsewhere on a competitive basis. (I/We) support this law, because it helps patients make reasoned financial decisions concerning their medical care. In compliance with the requirements of this law,please be advised that we have a direct financial interest in the following Surgical Centers:
Gateway Surgery Center Honor Health Pain Center Metro Surgery Center North Valley Ambulatory Surgery Center (Honor Health) North Scottsdale Ambulatory Surgery Center Paramount Surgery Center (Honor Health)
_____________________________ NAME
_________________ DATE
Permission to Pick-up Prescriptions
I __________________________________ give permission for the following person(s) to pick up my prescriptions on my behalf: ________________________________________________________ (Name(s) of authorized person(s) I understand that no one other than the above listed person(s) will be able to pick up my prescriptions. I understand that if something should happen to the prescriptions while in the possession of the listed person(s), I am still fully responsible. This consent is good for one year from date signed unless you notify the office in writing of a change.
Patient Signature _______________________________ Date __________ Staff Initials ______ Date __________
