PDF - Seattle Pain Centers
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: _____________________________ Address: _________________________________City: ____________________________State: ___________ Zip: ____________ 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: _____________________________________ Address: _________________________________City: ____________________________State: ___________ Zip: ____________ EMERGENCY CONTACT INFORMATION Name: ____________________________________ Phone: _________________ Relationship to patient: ____________________ ATTORNEY INFORMATION Name: _______________________________________________________ Phone:________________________________________ Address: _________________________________City: ____________________________State: ___________ Zip: ____________ Injury / Illness Date: ______/_______/_______ Auto? _____________ Other Accident: __________________________________ LIEN - Fill out below if L&I or PI / Auto Insurance (If you have medical coverage) Insurance: _____________________________________________________________ Phone: ______________________________ Address: _________________________________City: ____________________________State: ___________ Zip: ____________ 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 I authorize the clinic to leave detailed messages about appointments/phone calls: YES Work Cell 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:______________ PAIN HISTORY REFERRED BY: PATIENT NAME: _____________________________________ ___________________ DATE OF BIRTH: ___________________ TODAY’S DATE: ________________ Physician Notes: (Physician use only) Chief Complaint:_________________________________________________ PAIN COMPLAINTS (List your pain and their intensities) PAIN STARTED on DATE: _______________________ 1. mild moderate _______________________ 2. mild moderate mild moderate mild moderate mild ABOUT YOUR PAIN TIMING DESCRIPTION moderate OTHER after heavy lifting severe 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 Dull Heavy Pressure Sharp Stabbing Electrical Pins and Needles Numbness Burning Throbbing Pounding Aching Radiates to ______________ OTHER: © 2009 SEATTLE PAIN CENTER severe 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: ✔ severe after falling _______________________ 5. due to Auto Accident _______________________ 4. due to Job Injury on its own severe _______________________ 3. severe ________________________ suddenly gradually 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: Page 1 of 5 PAIN HISTORY FOR HEADACHES PATIENT NAME: _____________________________________ ASSOCIATED WITH HOW OFTEN? daily weekly monthly seasonal several times a day several times a week several times a month several months at a time Typically Lasting: minutes hours days 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 MRI Places _____________ Results (Physician Notes) _________________________ CT _____________ _________________________ X-rays _____________ _________________________ Bone scan _____________ _________________________ Myelogram _____________ _________________________ EMG/NCV _____________ _________________________ OTHER _____________ _________________________ THERAPIES TRIED MEDICATIONS TRIED OPIOIDS TRIED (and COMPLICATIONS?) Physical therapy NSAIDS helpful not helpful TENS Lidoderm helpful not helpful Epidural injections Flector helpful not helpful Trigger Point Injections Gabapentin helpful not helpful Other injections Antidepressants helpful not helpful Pain Pump Muscle Relaxant helpful not helpful Spinal Cord Stimulation OTHER: Medications OTHER: Vicodin __________________________ Darvocet __________________________ Percocet __________________________ Dilaudid __________________________ Morphine __________________________ Oxycodone __________________________ Oxycontin __________________________ Methadone __________________________ © 2009 SEATTLE PAIN CENTER Page 2 of 5 PAIN HISTORY PATIENT NAME: _____________________________________ Duragesic __________________________ Actiq __________________________ Fentora __________________________ Opana __________________________ OTHER: PAIN MEDICATIONS OTHER MEDICATIONS (current medications) ALLERGIES © 2009 SEATTLE PAIN CENTER Page 3 of 5 PAIN HISTORY PATIENT NAME: _____________________________________ 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 WORK HISTORY Occupation:___________________ Currently working Not working Are you pregnant? Yes No Date Last worked?__________ DISABILITY: Seeking Already rated Medicare Date of last menstrual period? ______________________________ © 2009 SEATTLE PAIN CENTER FAMILY HISTORY Diabetes Cancer Heart disease Hypertension Stroke Arthritis Back Problems OTHER: Page 4 of 5 PAIN HISTORY 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 PATIENT NAME: _____________________________________ 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 © 2009 SEATTLE PAIN CENTER Page 5 of 5 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. 6. Uses of Protected Health Information to Contact You We may use your Protected Health Information to contact you regarding appointment reminders or to 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: _________________ Financial Policy Insurance Payment: • Your 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 the insurance carrier. Read it, understand it, and ask questions. Your insurance does not automatically cover everything. Even different polices from the same insurance company can have different requirements. It is YOUR responsibility to know what your policy covers and what it does not, and also, whether you need referrals or primary care physician listed. Non-Insurance Payment: • For those patients without insurance, payment is required in full at the time of service. 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 payment is to be paid at the time of service. If payment is not made within 48 hours and a bill is sent out, there is a $10 surcharge added to the visit. Missed Appointment: appointment, you need to call at least Twenty-Four Twenty (24) • 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 appointment, they will be charged ed a $50 fee. This charge 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 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 late fees. Payment Arrangement: cumstances, payment arrangements may be made with our billing • Under special circumstances, 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. payment will result in a delinquent status and the special • Missed payments or non-payment arrangement may be terminated. Any account(s) going into default will be sent to collections without further notice! _____________________________ ____________________________________ Print Name ____________________________________ _____________________________ Signature & Date Opioid Treatment Agreement Opioid (narcotic) treatment for chronic pain is used to reduce pain and improve what you’re able to do 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 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: ______________________________________________________ ________________________________________________________________________________ CONTACT 2: (please print) Name ___________________________________ Relationship to patient _____________________ Contact Number (______) _______-_________ Emergency Response Person: YES / NO Limitations in communications: ______________________________________________________ ________________________________________________________________________________ CONTACT 3: (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: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
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