Name: Date of Birth: Social Security #: Home # Cell # Address: City: State: Zip: Emergency Contact #: Relationship:

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California Back and Pain Specialists

14624 Sherman Way, Suite 309, Van Nuys, CA 91405

1172 Swallow Lane, Simi Valley, CA 93065

101 Hodencamp Road, Suite 103, Thousand Oaks, CA 91360 9201 Sunset Blvd, Suite 812, Los Angeles, CA 90069

10610 Lower Azusa Road, El Monte, CA 91731 2808 F Street, Suite C, Bakersfield, CA 93301

(Phone) 818-884-5480 (Fax) 818-884-5490

PERSONAL INJURY

Date: __________

Name: _______________________________________________________________________ Date of Birth: ______________________________Social Security #: __________________ Home # _______________________ Cell # _________________________________________ Address: _____________________________________________________________________ City: ______________________________ State: ______________ Zip: __________________ Referred by:

______________________________________________________________________________ Primary Treating Physician:

______________________________________________________________________________ Emergency Contact:

______________________________________________________________________________ Emergency Contact #: ____________________ Relationship: __________________________ Date of injury: ____________________

0 Car accident 0 Slip and Fall

Were you the driver, passenger, or in the back seat? _________________________________ Was a police report filed? 0 YES 0 NO

Where did the accident occur? _________________________________________________ Please briefly explain how the accident occurred.

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Name: _______________________________________________________________________ Date of Birth:

____

___Age:_

___

___ Sex: _

___

____ Height: ____

___

_ Weight:

_______

Current Symptoms

Where is your pain?

__________________________________________________

Please mark an “X” on the figure below where your pain starts and show where it goes using an arrow:

R L L R R L R L Describe the circumstances around the onset of your pain:

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PAGE 3 How often is your pain?

0 Occasional 0 Frequent 0 Constant

Does the pain radiate? If so, where to?

______________________________________________________________________________ Circle the number that best describes how severe your pain is: (0= none; 10=worst)

Do you experience any of the following? If yes, please explain 0 Weakness 0 Muscle Spasms 0 Stiffness

0 Limping 0 Numbness 0 Tingling

0 Headaches

How long can you do the following until the pain interferes?

Sit ___________ minutes. Stand ___________minutes. Walk __________ minutes. Have you avoided strenuous lifting, carrying, pushing, pulling, stooping, and bending because of your injury?

0 Yes 0 No

How do the following factors affect your pain?

Better Worse No Effect

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Medical History

Please list all current and past MEDICAL PROBLEMS:

______________________________________________________________________________ ______________________________________________________________________________ Current Medications: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ List allergies or reactions to medications:

______________________________________________________________________ ______________________________________________________________________ Do you take any blood thinning medications? If yes which of the following?

0 Aspirin 0 Coumadin 0 Plavix 0 Heparin 0 Pletal 0 Lovenox 0 Ticlid Please list all surgeries and their dates:

______________________________________________________________________ ______________________________________________________________________ Family Medical History: please list any illness or disease that runs in your family. ______________________________________________________________________ Circle One: 0 Single 0 Married 0 Divorced 0 Widowed

Occupation:

______________________________________________________________________ Do you use tobacco? If yes please describe:

______________________________________________________________________ Do you consume alcohol? If yes please describe:

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California Back and Pain Specialists

(Phone) 818-884-5480 (Fax) 818-884-5490

RELEASE OF RECORDS AUTHORIZATION

To: _______________________ _______________________ _______________________ Patient: _____________________ SS#: ________________________ DOB: _______________________

I authorize you, your agent, or legal representative to release and disclose as requested all the medical information, including but not limited to records of examinations, treatments,

consultations, billing records, diagnostics and laboratory findings, admissions and discharge reports, treatment and prognosis records, nurses and doctors notes and any other non-medical information in my file.

Please send all the above to:

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Vik Singh, M.D./ Ryan Peterson, M.D.

California Back and Pain Specialists

(Phone) 818-884-5480 (Fax) 818-884-5490

MEDICATION DISPENSE AGREEMENT

The purpose of this agreement is to prevent misunderstanding about certain

medications you will be taking for pain management. This is to help both, you and your doctor to comply with the law regarding controlled pharmaceuticals.

This agreement is essential to the trust and confidence necessary in a doctor/ patient relationship.

I understand that if I break this agreement, my doctor will stop prescribing pain control medication. In this case, the doctor may taper off the medicine over a period of several days as necessary to avoid withdrawal symptoms. The doctor may recommend a drug dependency treatment program as well.

I understand that it is imperative to fully communicate with the doctor about the character and intensity of the pain, as well as the effect of pain on daily living and the benefit the medication is providing to relieve the pain.

I agree not to use any illegal controlled substances.

I agree I will not share, sell or trade my medication with anyone.

I agree I will not attempt to obtain any controlled medication from other physicians. I agree to safeguard my medications from loss or theft. In the event of lost or stolen

medication, a police report will be required but does not guarantee a refill will be provided. I agree the refilling of my medications will be made on the day of my scheduled follow up office visit and/or during regular office hours. No refills will be made evenings, holidays or

weekends.

I agree that I will submit a blood or urine test at the doctor‟s discretion in the event of determining the patient‟s compliance with the medication agreement.

I agree to take the medication at the rate and frequency as prescribed. I fully understand the noncompliance could result in being without medication for a period of time.

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Vik Singh, M.D./ Ryan Peterson, M.D.

California Back and Pain Specialists

(Phone) 818-884-5480 (Fax) 818-884-5490

ABSOLUTELY NO EARLY REFILLS.

By signing below, I fully acknowledge what I have read above and I agree to comply with this agreement.

I understand the noncompliance could result in treatment being discontinued and patient being discharged, and\or referred to an addiction specialist.

Please feel free to address any cares or concerns with the doctor or his staff. Patient name: _________________________________________________ Patient signature: ______________________________________________ Date: _________________________________________________________

Acknowledgement that our physicians are governed by the Medical Board of California. Medical doctors are licensed and regulated by the Medical Board of California.

800-633-2322 www.mbc.ca.gov

I understand that Dr. Vik Singh/Ryan Peterson is licensed and regulated by the Medical Board of California.

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California Back and Pain Specialists

(Phone) 818-884-5480 (Fax) 818-884-5490

Acknowledgement of Receipt of Information Practices Notice (§164.520(a))

I,_______________________________, (patient‟s name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I acknowledge that I have been provided with and understand that this facility‟s

Notice of Privacy Practices provides a complete description of the uses and disclosures of my

health information. I understand that:

� I have the right to review this facility„s Notice of Privacy Practices prior to signing this acknowledgement;

� This facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I've provided if requested.

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Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I, ___________________________________, (patient‟s name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment;

A means of communication among the health professionals who may contribute to my healthcare; A source of information for applying my diagnosis and surgical information to my bill;

A means by which a third-party payer can verify that services billed were actually provided;

A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility‟s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

I have the right to review this facility‟s Notice of Information practices prior to signing this consent; This facility, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I‟ve provided if requested;

I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested. I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.

It is this facility‟s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

Signature of Patient or Legal Representative Witness ……….………..

Printed Name of Patient or Legal Representative Witness ………

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