PATIENT INFORMATION FORM

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PATIENT INFORMATION FORM

Date: ______/______/______

PATIENT INFORMATION

Last Name: _____________________________First Name: ____________________________Middle Initial: _____Sex: M F Date of Birth: _______/_______/_______ Social Security #:________-______-________ Drivers Lic #:______________________

Address: _________________________________City: ____________________________State: ___________ Zip: ____________

Home #: _________________________ Cell #: _________________________ Marital Status: _____________________________

REFERRAL INFORMATION

Referred By: ____________________________________________________________ Phone: _____________________________

POLICY HOLDER (If different than patient)

Last Name: _____________________________First Name: ____________________________Middle Initial: _____Sex: M F Date of Birth: _______/_______/_______ Social Security #:________-______-________ Drivers Lic #:______________________

Address: ______________________________________Home #: ________________________ Cell #: _______________________

Name of Employer: __________________________________________________ Phone: _________________________________

INSURANCE INFORMATION

Primary Insurance Plan: ___________________________________ Policy Holders Name: _______________________________

ID #: ________________________________ Group #:_____________________________ Phone: __________________________

Secondary Insurance Plan: _________________________________Policy Holders Name: ________________________________

ID #: ________________________________ Group #:______________________________ Phone: _________________________

EMPLOYER INFORMATION

Employer: ______________________________________________________ Phone: _____________________________________

EMERGENCY CONTACT INFORMATION

Name: ____________________________________ Phone: _________________ Relationship to patient: ____________________

ATTORNEY INFORMATION

Name: _______________________________________________________ Phone:________________________________________

Injury / Illness Date: ______/_______/_______ Auto? _____________ Other Accident: __________________________________

LIEN - Fill out below if L&I or PI / Auto Insurance (If you have medical coverage)

Insurance: _____________________________________________________________ Phone: ______________________________

Claim Adjuster: __________________________________________ Claim #:___________________________________________

Policy Holder: _______________________________________________________________________________________________

HIPAA INFORMATION:Instructions for the office when returning phone calls or reminding you about your appointments.

I authorize the clinic to contact me at: Home Work Cell and may leave messages at: Home Work Cell I authorize the clinic to leave detailed messages about appointments/phone calls: YES NO

If you prefer us to leave messages with a specific individual, please list them below:

1. _______________________________ 2. ________________________________ 3. ______________________________________

Patient (or Parent/Guardian) Signature ____________________________________________ Date:______________

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REFERRED BY: ___________________DATE OF BIRTH: ___________________ TODAY’S DATE:________________

Physician Notes: (Physician use only)

Chief Complaint:_________________________________________________

PAIN COMPLAINTS (List your pain and their intensities)

1. _______________________

mild moderate severe

2. _______________________

mild moderate severe

3. _______________________

mild moderate severe

4. _______________________

5. _______________________

PAIN STARTED on DATE:

________________________



suddenly gradually on its own

due to Job Injury due to Auto Accident

after falling after heavy lifting



OTHER

ABOUT YOUR PAIN TIMING

 Constant

 Comes and goes

 Frequent

 Worse in am

 Worse in pm

 Began <6 mo ago

 Began < 1 yr ago

 Began 1-2yrs ago

 Began 2-3 yrs ago

 Began 3-5 yrs ago

 Began >5 yrs ago

 Worsening

 Stable

 Improving

DESCRIPTION

 Dull

 Heavy

 Pressure

 Sharp

 Stabbing

 Electrical

 Pins and Needles

 Numbness

 Burning

 Throbbing

 Pounding

 Aching

 Radiates to ______________

OTHER:

INCREASED BY

 Activity

 Walking

 Standing

 Sitting

 Twisting

 Lifting

 Reaching

 Rising from a chair

 Walking DOWN stairs

 Walking UP stairs

 Coughing

 Sneezing

 Defecating

 Intercourse

 Cold

 Stress OTHER:

DECREASED BY

 Activity

 Rest

 Sleeping

 Lying still

 Walking

 Standing

 Sitting

 Medications

 Injections

 Heat

 TENS

 Acupuncture OTHER:

IN THE PAST WEEK

Average Pain: _______(0-10) Pain at Worst:_______(0-10) Pain at Best: _______(0-10) 0 = No pain

10 = Unbearable pain ASSOCIATED WITH

 Urinary incontinence

 Fecal incontinence

 New onset weakness in __________________

OTHER:

✔

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PAIN HISTORY

PATIENT NAME:_____________________________________

Page 2 of 5

FOR HEADACHES HOW OFTEN?

daily several times a day

weekly several times a week

monthly several times a month

seasonal several months at a time Typically Lasting:  minutes hours days

ASSOCIATED WITH

light/sound sensitivity

nausea/vomiting

weakness in _________________________

visual disturbances

seizures

passing out

loss of bowel/bladder function

menstruation

PATTERN

entire head

head and neck

left-sided  right-sided

back of head

temples

in/around the eyes

radiates to

_________________________

DIAGNOSTIC STUDIES

Dates Places

 MRI _____________

_________________________

 CT _____________

_________________________

 X-rays _____________

_________________________

 Bone scan _____________

_________________________

 Myelogram _____________

_________________________

 EMG/NCV _____________

_________________________

 OTHER _____________

_________________________

Results (Physician Notes)

THERAPIES TRIED

 Physical therapy

 TENS

 Epidural injections

 Trigger Point Injections

 Other injections

 Pain Pump

 Spinal Cord Stimulation

 Medications

 OTHER:

MEDICATIONS TRIED

NSAIDS helpful  not helpful

Lidoderm helpful  not helpful

Flector helpful  not helpful

Gabapentin helpful  not helpful

Antidepressants  helpful  not helpful

Muscle Relaxant  helpful  not helpful OTHER:

OPIOIDS TRIED (and COMPLICATIONS?)

 Vicodin

__________________________

 Darvocet

__________________________

 Percocet

__________________________

 Dilaudid

__________________________

 Morphine

__________________________

 Oxycodone

__________________________

 Oxycontin

__________________________

 Methadone

__________________________

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 Duragesic

__________________________

 Actiq

__________________________

 Fentora

__________________________

 Opana

__________________________

OTHER:

PAIN MEDICATIONS OTHER MEDICATIONS (current medications)

ALLERGIES

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PAIN HISTORY

PATIENT NAME:_____________________________________

Page 4 of 5

PAST MEDICAL HISTORY CARDIOVASCULAR

 Pacemaker

 Coronary Artery Disease

 Valve-disease

 Hypertension

 Irregular heartbeats LUNG DISEASE

 Asthma

 Emphysema

 Shortness of breath

BLEEDING DISORDERS

 Yes

 No THYROID DISEASE

 Yes

 No ARTHRITIS

 Yes

 No

LIVER DISEASE

 Cirrhosis

 Hepatitis C

 Hepatitis B

 Hepatitis A KIDNEY DISEASE

 Stones

 Dialysis

 Kidney problems

DIABETES

 Insulin

 Medications

 Diet CANCER

Type:_______________________

OTHER

CONDITIONS (check conditions you have or have had in the past)

 AIDS

 Alcoholism

 Anemia

 Anorexia

 Appendicitis

 Arthritis

 Asthma

 Bleeding Disorders

 Breast Lump

 Bronchitis

 Bulimia

 Cancer

 Chemical Dependency

 Diabetes

 Emphysema

 Epilepsy

 Glaucoma

 Goiter

 Gonorrhea

 Gout

 Heart Disease

 Hepatitis

 Hernia

 Herpes

 High Cholesterol

 HIV Positive

 Kidney Disease

 Liver Disease

 Measles

 Migraine Headaches

 Mononucleosis

 Multiple Sclerosis

 Mumps

 Pacemaker

 Pneumonia

 Polio

 Prostate Problems

 Psychiatric Care

 Rheumatic Fever

 Shingles

 Stroke

 Suicide Attempt

 Thyroid Problems

 Tonsillitis

 Tuberculosis

 Typhoid Fever

 Ulcers

 Venereal Disease PAST SURGICAL HISTORY

Year Surgery Surgeon/Complications

PSYCHOSOCIAL HISTORY MARITAL STATUS

single married

divorced  widowed

live alone HABITS

 Smoking ___ Packs/day

 Alcohol ____ Amount

 Medication Abuse

 Recreational Drugs _____________________

 Drug Rehab

PERSONAL ABUSE HISTORY

 sexual abuse

 physical abuse

 emotional abuse

Are you pregnant?^Yes  No Date of last menstrual period?

______________________________

WORK HISTORY

Occupation:___________________

 Currently working

 Not working

Date Last worked?__________

DISABILITY:

 Seeking

 Already rated

 Medicare

FAMILY HISTORY

 Diabetes

 Cancer

 Heart disease

 Hypertension

 Stroke

 Arthritis

 Back Problems OTHER:

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REVIEW OF SYSTEMS GENERAL

 Weight loss

 Weight gain

 Fatigue

 Fever

SKIN

 Rash

 Color changes

 Redness

 Itching

 Swelling

HEMATOLOGY

 Bleeding

 Blood Clots

HEENT

 Vision Loss

 Double vision

 Glasses

 Eye pain

 Hearing Loss

 Dizziness

 Tooth/gum pain

CARDIOVASCULAR

 High Blood Pressure

 Chest Pain on Exertion

 Irregular Heart Beat

 Murmur

 Shortness of Breath

RESPIRATORY

 Chronic cough

 Coughing up blood

GASTROINTESTINAL

 Nausea/Vomiting

 Heartburn

 Constipation

 Diarrhea

 Bloody Stools

 Black Tarry Stools

 Abdominal Pain

 Trouble Swallowing

GENITOURINARY

 Bloody Urine

 Urgency/Incontinence

 Pain with Urination

MUSCULOSKELETAL

 Joint Pain

 Stiffness

 Limp

 Spasms

 Muscle Pain

 Limited Movement

PSYCHOLOGICAL

 Active Suicidal Thoughts

 Depression

 Anxiety

 Sleeping Problems

NEUROLOGICAL

 Seizures

 Weakness in _____________

 Numbness in _____________

 Passing Out

 Facial Pain

 Headaches

ENDOCRINE

 Excessive Sweating

 Excessive Thirst

 Always Cold

 Always Hot

I certify that the above information is correct to the best of my knowledge. I will not hold my

doctor or any members of his/her staff responsible for any errors or omissions that I may

have made in the completion of this form.

__________________________________________________ __________________________

Patient Signature Date

__________________________________________________ __________________________

Witness Date

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Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. NOTICE OF PRIVACY PRACTICES PURSUANT TO 45 C.F.R. S 164.520

1. Our Duties

We are required by law to maintain the privacy of your Protected Health Information (“Protected Health Information”). We must also provide you with notice of our legal duties and privacy practices with respect to Protected Health Information. We are required to abide by the terms of our Notice of Privacy Practices currently in effect. However, we reserve the right to change our privacy practices in regard to Protected Health Information and make new privacy policies effective for all Protected Health Information that we maintain. We will provide you with a copy of any current privacy policy upon your written request, addressed to our Privacy Officer, at our current address.

2. Your Complaints

You may complain to us and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. You may file a complaint with us by sending a certified letter addressed to “Privacy Officer” at our current address, stating what Protected Health Information you believe has been used or disclosed improperly. You will not be retaliated against for making a complaint. For further information you may contact our Privacy Officer, at telephone number 212-604-1332.

3. Description and Examples of Uses and Disclosures of Protected Health Information

Here are some examples of how we may use or disclose your Protected Health Information. In connection with treatment, we will, for example, allow a physician associated with us to use your medical history, symptoms, injuries or diseases to treat your current condition. In connection with payment, we will, for example, send your Protected Health Information to your insurer or to a federal program, such as Medicare, that pays for your treatment. This allows us to obtain payment for the services we rendered on your behalf. In connection with health care operations, we will, for example, allow our auditors, consultants, or attorneys’ access to your Protected Health Information to determine if we billed you accurately for the services we provided to you.

4. Uses and Disclosures Which Require Your Written Authorization

Uses and disclosures other than those involving treatment, payment, and health care operations, as well as those described in the following sections of this Notice, will only be made by obtaining a written authorization from you. You may revoke this authorization in writing at any time, except to the extent that we have taken action in reliance upon your authorization.

5. Uses and Disclosures Not Requiring Your Written Authorization

The privacy regulations give us the right to use and disclose your Protected Health Information if: (I) you are an inmate in a correctional institution; (ii) we have a direct or indirect treatment relationship with you, (iii) we are so required or authorized by law. The purposes for which we might use your Protected Health Information would be to carry out treatment, payment, and health care operations similar to those described in Paragraph 1.

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contact you with information about treatment alternatives or other health-related benefits and services that, in our opinion, may be of interest to you. We may use your Protected Health Information to contact you in an effort to raise funds for our operations.

7. Disclosures of Protected Health Information for Billing Purposes

We may disclose your billing information to any person that calls our billing staff or agents with billing questions after we verify the identity of the person by requesting information such as your social security number or health plan number.

8. Disclosures for Directory and Notification Purposes

If you are incapacitated or not present at the time, we may disclose your Protected Health Information (a) for use in a facility directory, (b) to notify family or other appropriate persons of your location or condition, and (c) to inform family, friends or caregivers of information relevant to their involvement in your care or payment for your treatment. If you are present and not incapacitated, we will make the above disclosures, as well as disclose any other information to anyone you have identified, only upon your signed consent, your verbal agreement, or the reasonable belief that you would not object to such disclosure(s).

9. Individual Rights

(i) You may request us to restrict the uses and disclosures of your Protected Health Information, but we do not have to agree to your request. (ii) You have the right to request that we communicate with you regarding your Protected Health Information in a confidential manner or pursuant to an alternative means, such as by a sealed envelope rather than a postcard, or by communicating to a specific phone number, or by sending mail to a specific address. We are required to accommodate all reasonable requests in this regard. (iii) You have the right to request that you be allowed to inspect and copy your Protected Health Information as long as it is kept as a designated record set, and as long as you pay in advance for the administrative time and costs to make arrangements to have the records inspected and copied. Certain records are exempt from inspection and cannot be inspected or copied, so each request will be reviewed in accordance with the standards published in 45 C.F.R. S 164.524. (iv) You have the right to amend your Protected Health Information for as long as the Protected Health Information is maintained in the designated record set. We may deny your request for an amendment if the Protected Health Information was not created by us, or is not part of the designated record set, or would not be available for inspection as described under section 45 C.F.R. S 164.524, or if the Protected Health Information is already accurate and complete without regard to the amendment. (v) You have the right to request, and thereafter receive, an accounting of the disclosures of your Protected Health Information for six years before the date on which you request the accounting.An exception to this accounting are those disclosures not allowed by law pursuant to section 164.528. Each request for an accounting will be reviewed pursuant to the rules of section 164.528. (vi) You also have a right to receive a copy of this Notice upon request.

10. Effective Date

The effective date of this Notice is January 01, 2008.

Signature of Patient or Authorized Representative:

___________________________________________________________________

Print Name _________________________________________________________

Relationship: _________________________________ Date: _________________

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Insurance Payment:

• Your insurance card and photo I.D are

• Read and understand your insurance policy. Your policy is a contract between you and the insurance carrier. Read it, understand it, and

automatically cover everything. Even different polices from the same insurance company can have different requirements. It is

covers and what it does not, and also, whether physician listed.

Non-Insurance Payment:

• For those patients without insurance, payment

Upon request, we will be happy to provide you with an estimate of the cost for specific services before your appointment.

• We accept cash and major credit cards.

Co-Pays:

• Co-payment is to be paid at the time of service.

and a bill is sent out, there Missed Appointment:

• If you cannot attend a scheduled appointment

hours in advance to notify our office. Patients who fail to inform the office of the above or fail to show for a scheduled appointment

will be collected at the time of your next scheduled appointment and / or will be billed to you directly. We will not bill your insurance company for missed appointments.

Tardiness:

• If you are more than twenty minutes late to a

be charged. This charge will be collected at the time of your next appointment and / or will be billed to you directly.

Payment Arrangement:

• Under special circumstances, payment arrangements may be made with our billing department. Payments must be paid on a monthly basis. Payment arrangements apply to the existing balance only. All subsequent services must be paid according to office policy.

• Missed payments or non-payment will result in a delinquent status and the special arrangement may be terminated. Any account(s) going into default will be sent to collections without further notice!

____________________________________

Print Name

Financial Policy

insurance card and photo I.D are required at the time of each appointment.

Read and understand your insurance policy. Your policy is a contract between you and insurance carrier. Read it, understand it, and ask questions. Your insurance does not automatically cover everything. Even different polices from the same insurance company

have different requirements. It is YOUR responsibility to know what your policy what it does not, and also, whether you need referrals or primary care

For those patients without insurance, payment is required in full at the time of service.

request, we will be happy to provide you with an estimate of the cost for specific before your appointment.

We accept cash and major credit cards.

payment is to be paid at the time of service. If payment is not made within 48 hours there is a $10 surcharge added to the visit.

cannot attend a scheduled appointment, you need to call at least Twenty

hours in advance to notify our office. Patients who fail to inform the office of the above fail to show for a scheduled appointment, they will be charged a $50 fee. This charge collected at the time of your next scheduled appointment and / or will be billed to directly. We will not bill your insurance company for missed appointments.

If you are more than twenty minutes late to a scheduled appointment, a $50 late fee will be charged. This charge will be collected at the time of your next appointment and / or will be billed to you directly. We will not bill your insurance company for

cumstances, payment arrangements may be made with our billing department. Payments must be paid on a monthly basis. Payment arrangements apply to

existing balance only. All subsequent services must be paid according to office payment will result in a delinquent status and the special arrangement may be terminated. Any account(s) going into default will be sent to

without further notice!

_____________________________ ____________________________________

Signature & Date

time of each appointment.

Read and understand your insurance policy. Your policy is a contract between you and ask questions. Your insurance does not automatically cover everything. Even different polices from the same insurance company

responsibility to know what your policy you need referrals or primary care

in full at the time of service.

request, we will be happy to provide you with an estimate of the cost for specific

If payment is not made within 48 hours

need to call at least Twenty-Four (24) hours in advance to notify our office. Patients who fail to inform the office of the above

ed a $50 fee. This charge collected at the time of your next scheduled appointment and / or will be billed to directly. We will not bill your insurance company for missed appointments.

scheduled appointment, a $50 late fee will be charged. This charge will be collected at the time of your next appointment and / or

We will not bill your insurance company for late fees.

cumstances, payment arrangements may be made with our billing department. Payments must be paid on a monthly basis. Payment arrangements apply to

existing balance only. All subsequent services must be paid according to office payment will result in a delinquent status and the special arrangement may be terminated. Any account(s) going into default will be sent to

_____________________________

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each day.

Along with opioid treatment, other medical care may be prescribed to help improve your ability to do daily activities. This may include exercise, use of non-narcotic analgesics, physical therapy, psychological counseling or other therapies or treatment.

I, __________________________, understand the compliance with the following guidelines is important in continuing pain treatment with the Seattle Pain Center. I understand that I have the following

responsibilities and agree to adhere to all of the following rules while I am under the care of Seattle Pain Center:

1. I will take medications as prescribed.

2. I will not increase or decrease without the approval of my physician.

3. I will not obtain medications from several physicians, but my physician only. (Under certain circumstances, if I obtain any additional narcotic from other physicians such as primary care physician or emergency room physician, then I will immediately notify Seattle Pain Center.) 4. I will not share the medication with anyone including family members.

5. I will not sell the medication.

6. I will not get replacement from any lost or stolen medication regardless of the circumstance.

7. I will not get early refills.

8. I will notify if I use alcohol or other illicit drugs along with pain medication.

9. I agree to periodic random drug screening tests.

10. I agree to periodic random pill counts.

11. I agree to participate in adjunctive pain management programs such as: psychological aspects of pain management, counseling therapy, stress reduction program, pain coping skills, behavioral modification, biofeedback, and physical therapy if recommended by the physician.

12. I agree to taper off from Opioid pain medication if I feel there is no improvement in pain control or daily functional ability with medication.

13. I will not request prescription refills when the clinic is closed after hours or on weekends.

14. If I am pregnant or intend to get pregnant, I am required to notify Seattle Pain Center immediately to discuss tapering off Opioid and/or benzodiazepam-type medications that could potentially harm the fetus. I understand that failure to do so may result in discharge from the clinic. I will not hold the clinic responsible for any harm that may occur to me and/or my unborn.

I, __________________________, understand that this physician may stop prescribing the medication or change the treatment plan if I failed to follow the above recommendations.

I have read this document, understand and have had all my questions answered satisfactorily.

I consent to the use of Opioids to help control my pain and I understand that my treatment with Opioids I will be carried out as described above.

_______________________________________ _______________________________________

Print Patient Name Patient Signature & Date

_______________________________________ _______________________________________

Print Witness Name Witness Signature & Date

_______________________________________ _______________________________________

Print Physician Name Physician Signature & Date

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Patient Approved Contact

PATIENT NAME (please print): _______________________________ Date of Birth: ____/____/____

NOT DESIGNATING ANYONE AT THIS TIME Initials: _______ Today’s Date: ____/____/____

PLEASE NOTE: In authorizing these individuals we will also assume that there are no limitations in communications regarding the patient unless otherwise noted. If any individual other than those listed below contacts Seattle Pain Center regarding the above named patient’s personal health information, he or she will be referred back to the patient.

CONTACT 1: (please print)

Name ___________________________________ Relationship to patient _____________________

Contact Number (______) _______-_________ Emergency Response Person: YES / NO Limitations in communications: ______________________________________________________

________________________________________________________________________________

SIGNATURE (Patient/Representative)

X

_____________________ Today’s Date: _____/_____/_____

IF signed by Representative, describe authority to act on behalf of patient:

_____________________________________________________________________________________