CPC New Patient Intake Forms 10.2017 - Colorado Pain Care€¦ · q Hemorrhoid surgery _____ q...
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Today’s Date _______ _________ Your completed intake paperwork helps our Providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best care possible. If you have any questions or are unsure about how to complete any section of this form, inquire at our front desk or call 303-277-0700. Your Name __________________________________________ Driver’s License #/State ________________________ Social Security Number: ____ Date of Birth: _____ _______ Age: ______ Gender: q Male q Female Street Address: _________________________________________ __ _ City/State/Zip: _________________________________________ Email: _______ __________ Physical Address Same as Mailing? q Yes q No If not, please list mailing address: ____ ______________________________________________________________________________ __________________________________________________________________________________________ Preferred Phone: _____ q Home q Mobile q Work Secondary Phone: _____ q Home q Mobile q Work Emergency Contact Name: ___________________________________________ Phone: _________________ Relationship: __________________________________ Race: q American Indian or Alaskan Native q Asian or Pacific Islander q Black q White q Refuse to Report Ethnicity: q Hispanic q Non-Hispanic q Refuse to Report Primary Language: q English q Spanish q Other __________________________________________________ Who is your Primary Care Provider? ____________________________________________________________ Were you referred to our clinic by another physician? If so, whom? Ä If not, how did you hear about us? q TV q Radio q Insurance Company q Family q Friend q PCP q www.coloradopaincare.com q Facebook q Twitter q YouTube q Other Website _______ Patient Information Referral Social Status
Transcript of CPC New Patient Intake Forms 10.2017 - Colorado Pain Care€¦ · q Hemorrhoid surgery _____ q...
Today’sDate _______ _________
YourcompletedintakepaperworkhelpsourProvidersgettoknowyouandyourmedicalhistory.Werelyonitsaccuracyandcompletenesstoprovideyouwiththebestcarepossible.Ifyouhaveanyquestionsorareunsureabouthowtocompleteanysectionofthisform,inquireatourfrontdeskorcall303-277-0700.
YourName__________________________________________
Driver’sLicense#/State________________________ SocialSecurityNumber: ____
DateofBirth: _____ _______ Age: ______ Gender: qMale qFemale
StreetAddress: _________________________________________ __ _
City/State/Zip: _________________________________________
Email:_______ __________
PhysicalAddressSameasMailing? qYes qNo Ifnot,pleaselistmailingaddress: ____ ______________________________________________________________________________
__________________________________________________________________________________________
PreferredPhone: _____ qHome qMobile qWork
SecondaryPhone: _____ qHome qMobile qWork
EmergencyContactName: ___________________________________________
Phone: _________________ Relationship: __________________________________
Race: qAmericanIndianorAlaskanNative qAsianorPacificIslander qBlackqWhite qRefusetoReport
Ethnicity: qHispanic qNon-Hispanic qRefusetoReport
PrimaryLanguage: qEnglish qSpanish qOther__________________________________________________
WhoisyourPrimaryCareProvider?____________________________________________________________
Wereyoureferredtoourclinicbyanotherphysician? Ifso,whom?
Ä Ifnot,howdidyouhearaboutus?qTVqRadio qInsuranceCompanyqFamilyqFriend qPCP
qwww.coloradopaincare.com qFacebook qTwitterqYouTube qOtherWebsite _______
PatientInformation
Referral
SocialStatus
MaritalStatus: qMarried qSingle qDivorced qWidowedqOther
PharmacyName: PhoneNumber:
StreetAddress: City/State/Zip:
DoyouhaveaPrescriptionDrugIDcard?qYesqNoMemberID#___________________________RXBin#_________________________________ RXGroup#______________________________________
Payer(e.g.BC/BS): Plan:
Policy/I.D.Number: GroupNumber:
Payer(e.g.BC/BS): Plan:
Policy/I.D.Number: GroupNumber:
Insurancepolicyholder:qSelf qSpouse qChild qOther:
PolicyHolderName: PolicyHolderGender:qFemale qMale
DateofBirth: SocialSecurityNumber:
CompletethissectiononlyifyourvisittodayisrelatedtoaWorkersCompensationclaim
WorkersCompCompany: ______________________________________________
AgentName: ___________ _____________ StateofInjury:______________
Phonenumber: Faxnumber:
ClaimNumber: Dateofinitialinjury:
IsyourpaintheresultofaMotorVehicleAccidentorPersonalInjury?qYes qNo
Icertifythattheaboveinformationisaccurate,completeandtrue.IgivemyconsentforArizonaPaintoretrieveandreviewmymedicationhistory.Iunderstandthatthiswillbecomepartofmymedicalrecord.
PatientSignature:_________________________________________________ Date:___________________
PreferredPharmacyInformation
PrimaryInsurancePlan
SecondaryInsurancePlan(ifany)
WorkersCompensationClaimInformation
InjuryClaim
Completethisboxifyouarenotthepolicyholderforyoursecondaryinsurance
Insurancepolicyholder:qSelf qSpouse qChild qOther:
PolicyHolderName: PolicyHolderGender:qFemale qMale
DateofBirth: SocialSecurityNumber:
Completethisboxifyouarenotthepolicyholderforyourprimaryinsurance
Today’sDate YourName: _______ ___ Height: Weight: ___ lbs
Whereisyourworstareaofpainlocated,pleaselistonearea?Whatisthemainreasonfortoday’svisit?
__________________________________________________________________________________________
Doesthepainradiate?,ifyes,where?___________________________________________________________
Pleaselistadditionalareasofpain______________________________________________________________
Approximatelywhendidthispainbegin?
Whatcausedyourcurrentand/orchronicpainepisode?
Howdidyourcurrentpainepisodebegin? qGradually qSuddenly
Sinceyourpainbegan,howhasitchanged? qDecreased qIncreased qStayedthesameUsethisdiagramtoindicatethelocationandtypeofyourpain.Markthedrawingwiththefollowinglettersthatbestdescribeyoursymptoms:
Whatisyourcurrentpainrightnow?_____
qAching qNumbness qSpasming qThrobbing
OnsetofSymptoms
PainDescription-Checkallofthefollowingthatdescribeofyourpain:
“N”=numbness“S”=stabbing“B”=burning“P”=pinsandneedles“A”=aching
qCramping qShock-like qSqueezing qTingling/Pins&Needles qHot/Burning qShooting qStabbing/Sharp/Dull qTiring/Exhausting
Whatwordbestdescribesthefrequencyofyourpain? qConstant qIntermittent
Whenisthepainatitsworst?qMorningsqDuringthedayqEveningsqMiddleofthenight
qBalanceProblems qBladderincontinence qBowelincontinence qChills
qDifficultyWalking qFevers qNausea qVomiting
qNumbness/Tingling?Pleaselistwhere_ _____________________________________________
qWeakness?Pleaselistwhere_________________________________________ __
qIHAVENOTRECENTLYDEVELOPEDANYOFTHEABOVECONDITIONS
Markallofthefollowingtestsyouhavehadthatarerelatedtoyourcurrentpainsymptoms:
qMRIofthe Date: Facility:
qX-rayofthe Date: Facility:
qCTscanofthe Date: Facility:
qEMG/NCVstudyofthe Date: Facility:
qUltrasoundofthe________________________ Date: Facility:
qOtherdiagnostictesting: qIHAVENOTHADANYDIAGNOSTICTESTSPERFORMEDFORMYCURRENTPAINCOMPLAINTS
Markanyofthefollowingpaintreatmentsyouhaveundergonepriortotoday’svisit:
qChiropractic qPhysicalTherapy qSpineSurgery qPsychologicalTherapy
qEpiduralSteroidInjection:checkalllevelsthatapplyqCervicalqThoracicqLumbar
qMedialBranchBlocksorFacetInjections:checkalllevelsthatapplyqCervicalqThoracicqLumbar
qRadiofrequencyAblation:checkalllevelsthatapplyqCervicalqThoracicqLumbar
qSpinalColumnStimulator:checkoneqTrialOnlyqPermanentImplant
qTriggerPointInjections,where____________________________________________________________
qOtherTreatments:
__________________________________________________________________________________________
PainFrequency
Inthepastthreemonthshaveyoudevelopedanynew:
DiagnosticTestsandImaging
PainTreatmentHistory
qIHAVENOTHADANYPRIORTREATMENTSFORMYCURRENTPAINCOMPLAINTS
Areyoutakingaprescribedblood-thinnermedication? qYesqNoIfyes,pleasecheckwhichone:
qAggrenox qCoumadin qEffient qEliquis qLovenox qPlavix qPletal qPradaxa qTiclid qWarfarin qXarelto qOther ____________ _________________
Whoprescribesyourbloodthinnermedication?Doctor’snameandphonenumber: __________________________________________________________________________________________
PleaselistALLmedicationsyouarecurrentlytaking.Attachanadditionalsheet,ifrequired.
MedicationName Dose Frequency MedicationName Dose Frequency
1. 7.
2. 8.
3. 9.
4. 10.
5. 11.
6. 12.
Pleaseindicateanysurgicalproceduresyouhavehaddoneinthepast,includingthedate,type,andanypertinentdetails.
AbdominalSurgery:qGallbladderremoval _________________ qAppendectomy _____________________
FemaleSurgeriesqCaesareansection ____________________ qHysterectomy ______________________ qLaparoscopy _______________________ qOvarian __________________________ HeartSurgeryqValvereplacement ___________________qAneurysmrepair____________________ qStentplacement ____________________ JointSurgeryqShoulder _________________________ qHip ____________________________ qKnee ____________________________
Spine/BackSurgeryqDiscectomy(levels)______________________ qLaminectomy ___________________________ qSpinalfusion(levels) ______________________ OtherCommonSurgeriesqHemorrhoidsurgery _______________________ qHerniarepair ___________________________ qThyroidectomy__________________________ qTonsillectomy ___________________________ qVascularsurgery _________________________ Pleaselistanyothersurgeriesanddates(attachanadditionalsheetifnecessary):____________________________________________________________________________________________________________________________________________________________________________________
PastsurgicalhistoryCurrentMedications
PastSurgicalHistory
qIHAVENEVERHADANYSURGICALPROCEDURESDONE
Areallergicto qIodineor qTape
Areyouallergictolatex?qYes qNo
Ifyes:Doyourequirespecialmedicationsorrescuemeasurestomanageyourlatexallergy qYes qNo
Areyouallergictoshellfish? qYes qNo
MarkallappropriatediagnosesastheypertaintoyourbiologicalMOTHERANDFATHERonly.
Arthritis
Cancer
Diabetes
Headaches
HeartDisease
HighBloodPressure
HighCholesterol
KidneyProblems
LiverProblems
Osteoporosis
RheumatoidArthritis
Seizures
Stroke
MotherFather
Othermedicalproblems:
qIHAVENOSIGNIFICANTFAMILYMEDICALHISTORY qIAMADOPTED(NoMedicalHistoryAvailable)
Doyouhaveanyallergiesorreactionstomedications? qYes qNo
Ifyes,pleaselistallmedicationsyouareallergictoandthereactionyouhave:MedicationName AllergicReactionType
EnvironmentalAllergies
LatexAllergy
FoodAllergies
FamilyHistory
DrugAllergies
Markthefollowingconditions/diseasesthatyouhavebeentreatedforinthepast:
GeneralMedicalqCancer–Type qDiabetes–Type qHIV/AIDSGastrointestinalqBowelIncontinenceqAcidReflux(GERD)qGastrointestinalBleedingqConstipationHead/Eyes/Ears/Nose/ThroatqGlaucomaqHeadachesqHeadInjuryqHyperthyroidismqHypothyroidismqMigrainesCardiovascular/HematologicqAnemia/BleedingDisordersqHeartAttackqHighBloodPressureqHypertensionqHighCholesterolqMitralValveProlapseqMurmurqPacemaker/DefibrillatorqPoorCirculationqStroke
RespiratoryqAsthmaqBronchitisq Emphysema/COPDqPneumoniaqTuberculosisqValleyFeverMusculoskeletalqAmputationqBursitisqCarpalTunnelSyndromeqFibromyalgiaqJointInjuryqOsteoarthritisqOsteoporosisqPhantomLimbPainqRheumatoidarthritisqVertebralCompressionFractureGenitourinary/NephrologyqBladderInfection(s)qDialysisqKidneyInfection(s)qKidneyStonesqUrinaryIncontinence
HepaticqHepatitisA–circleone activeinactiveunsureqHepatitisB–circleone activeinactiveunsureqHepatitisC–circleone activeinactiveunsureNeuropsychologicalqAlzheimerDiseaseqBipolarDisorderqDepressionqEpilepsyqMultipleSclerosisqParalysisqPeripheralNeuropathyqSchizophreniaqCRPS/ReflexSympatheticDystrophyqOtherDiagnosedConditions:
__________________________________________________________
Haveyoureceivedapneumoniavaccination?qYes qNoIfyes,when?___________________________
Areyoucapableofbecomingpregnant?qYes qNo Ifyes,areyoucurrentlypregnant?qYes qNo
Highestlevelofeducationobtained: qGrammarschool qHighSchool qCollege qPost-graduateAlcoholUse:qCurrentAlcoholismqDailyLimitedAlcoholUseqHistoryofAlcoholismqNeverDrinksAlcohol
TobaccoUse:qCurrentSmoker/TobaccoUserqFormerSmoker/TobaccoUser
PastMedicalHistory/ProblemList
ImmunizationHistory
SocialHistory
qSocialAlcoholUse qNeverSmokedorUsedTobaccoSocialHistoryContinued:DrugUse:qDeniesAnyIllegalDrugUseqCurrentlyUsingIllegalDrugs,list: ______ __________________________________ __________qCurrentlyUsingSomeoneElse’sPrescriptionMedications,list_____________________________________qFormerlyUsedIllegalDrugs(notcurrentlyusing);list ______________________________________________________________________________________________________________________________Haveyoueverabusednarcoticorprescriptionmedications? qYes qNoWhichones:___ ____________________________________________________________________________________________
Areyouworking? qYes qNoqStudentqRetiredAreyouondisability? qYes qNo
Doyouexercise? qYes qNo Ifyes,howmanydaysperweek?_______________________________
Whattypeofexercisedoyouperform?qBicycleqCardioqStrengthqSwimmingqWalking
Other____________________________________________________________________________________
Howmuchtimedoyouexerciseonthedaysthatyoudoexercise?___________________________________
Haveyouhadtwoormorefallsinthepastyear? qYes qNo
INSTRUCTIONS:Foreachquestion,pleaseindicateyourresponsebycirclinganumberfrom0to10.PleaseanswerallquestionsYOURPAIN: 0=NoPain 10=ExtremePain
Duringthepastweek,thebestmypainhasbeenis...........................012345678910
Duringthepastweek,theworstmypainhasbeenis........................012345678910
Duringthepastweek,myaveragepainhasbeen...............................012345678910
Duringthepast3months,myaveragepainhasbeen........................012345678910YOURFEELINGS:DuringthepastweekIhavefelt: 0=StronglyDisagree 10=StronglyAgree
Afraid...................................................................................................012345678910
Depressed...........................................................................................012345678910
Tired....................................................................................................012345678910
Activity
Anxious...............................................................................................012345678910
Stressed...............................................................................................012345678910
YOURCLINICALOUTCOMES:Duringthepastweek: 0=StronglyDisagree 10=StronglyAgree
Ihadtroublesleeping.........................................................................012345678910
Ihadtroublefeelingcomfortable……………………………………..……..….....012345678910
Iwaslessindependent.......................................................................012345678910
Iwasunabletowork(orperformnormaltasks)……….……………….…….012345678910
Ineededtotakemoremedication..………………………………………..………..012345678910
YOURACTIVITIES:DuringthepastweekIwasNOTableto: 0=StronglyDisagree 10=StronglyAgree
Gotothestore....................................................................................012345678910
Dochoresinmyhome.........................................................................012345678910
Enjoymyfriendsandfamily...............................................................012345678910
Exercise(includingwalking).................................................................012345678910
Participateinmyfavoritehobbies……………………………..……..…………....012345678910
Markthefollowingsymptomsthatyoucurrentlysufferfrom.Note:Diagnosedconditions/diseasesshouldbenotedunderPastMedicalHistoryaboveConstitutional:qChillsqDifficultySleepingqEasyBruising qEasyBruising qExcessiveSweatingqExcessiveThirstqFatigueqFevers qFevers qLowSexDriveqNightSweatsqUnexplainedWeightGain qUnexplainedWeightLossqWeakness
Cardiovascular/Respiratory:qChestPainqCoughqFaintingqHighBloodPressure qHighBloodPressure qIrregularHeartbeatqLightheadednessqShortnessofBreathDuringExertionqShortnessofBreathDuringRestqSwellingintheFeetqWheezingGastrointestinal:qAbdominalCrampsqAcidRefluxqConstipation qCoffeeGroundAppearanceinVomit
Genitourinary/Nephrology:qBloodinUrineqDecreasedUrineinFlow,FrequencyorVolume qErectileDysfunctionqFlankPainqPainfulUrinationqPelvicPressure qPelvicPressure
Musculoskeletal:qBackPainqJointPainqJointSwellingqMuscleSpasmsqNeckPain
Neurological:qDizzinessqHeadachesqInstabilityWhenWalkingqNumbness/Tingling
ReviewofSystems
Eyes:qRecentVisualChangesEars/Nose/Throat/Neck:qDifficultyHearingqEarachesqHayfever/Allergies qNosebleeds qNosebleeds qRecurrentSoreThroatsqRingingintheEarsqSinusProblems
qDarkandTarryStoolsqDiarrheaqHerniaqVomiting
qSeizures
Psychiatric:qAnxiety/StressqDepressedMoodqSuicidalThoughtsqSuicidalPlanning
Icertifythattheaboveinformationisaccurate,completeandtrue.
I authorizeColoradoPainCareandanyassociates, assistants, andotherhealth careproviders itmaydeemnecessary,totreatmycondition.Iunderstandthatnowarrantyorguaranteehasbeenmadeofaspecificresultorcure.Iagreetoactivelyparticipateinmycaretomaximizeitseffectiveness.IgivemyconsentforColoradoPaintoretrieveandreviewmymedicationhistory.Iunderstandthatthiswillbecomepartofmymedicalrecord.
IacknowledgethatIhavehadtheopportunitytoreviewColoradoPainCare’sNoticeofPrivacyPractices,whichisdisplayedforpublicinspectionatitsfacilityandonitswebsite.ThisNoticedescribeshowmyprotectedhealthinformationmaybeusedanddisclosed,andhowImayaccessmyhealthrecords.
IauthorizetheColoradoPainCaretoreleasemyProtectedHealthInformation(medicalrecords)inaccordancewithitsNoticeofPrivacyPractices.Thisincludes,butisnotlimitedto,releasetomyreferringphysician,primarycarephysician,andanyphysician(s) Imaybereferredto. IalsoauthorizeColoradoPainCaretoreleaseanyinformationrequiredinobtainingprocedureauthorizationortheprocessingofanyinsuranceclaims.
I understand that Colorado Pain Carewill not releasemy ProtectedHealth Information to any other party(includingfamily)withoutmycompletingawritten“PatientAuthorizationforUseandDisclosureofProtectedHealthInformation”form,availableatitsfacilityandonitswebsite.
Iagreetoconductmyself(andmyguestswillconductthemselves)atalltimesinanhonest,respectfulandnon-combativemannerinallcommunicationsandinteractionswithCPCstaff,patients,andvisitors.Iwillrefrainfrominappropriate,discriminatory,harassing,threatening,orabusivelanguageorbehavior.IagreetoreporttomyProvidersandCPCstaff,accurateandcompleteinformation,tothebestofmyknowledge,allrelevantmatterspertaining tomyhealth, includingmyuse,misuse,orabuseofmedications, controlled substances,drugsoralcohol.
IntheeventthatIamaskedtoprovideaurine,oralswaband/orbloodsample,Ivoluntarilyseeklaboratoryservicesandherebyconsenttoprovideaurineand/orbloodsampleasrequested.Ihavetherighttorefuse
MedicalHistoryandConsentforTreatment
specifictests,butunderstandthismayimpactmypainmanagementtreatment.Thisagreementcanberevokedbymeatanytimewithwrittennotificationandisvaliduntilrevoked.IherebyassigntotheLaboratorymyrighttotheinsurancebenefitsthatmaybepayabletomeforservicesprovided,arisingfromanypolicyofinsurance,self-insuredhealthplan,MedicareorMedicaid inmynameor inmybehalf. I furtherauthorizepaymentofbenefitsdirectlytotheLaboratory.IunderstandthatacceptanceofinsuranceassignmentdoesnotrelievemefromanyresponsibilityconcerningpaymentforlaboratoryservicesandthatIamfinanciallyresponsibleforallchargeswhetherornottheyarecoveredbymyinsurance.IalsoacknowledgethattheLaboratorymaybeanout-of-networkproviderwithmyinsurer.Paymentinfullisexpected30daysofbeingnotifiedofanybalancedue.IunderstandthatintheeventthatIfailtomakepaymentwhendue,thisaccountwillbereferredtoacollectionagencyforcollections.Inthatevent,thecontingencyfeeassessedbythecollectionagencywillbeaddedtotheprincipalandinterestdue.AndIwillbeadditionallyliableforattorneyfees.Bothcollectionagencyfeesandattorneyfeeswillincreasethebalanceyouowe.
Signed: Date:
