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: