PRE-PROCEDURE CONSULTATION, HISTORY & PHYSICAL …



NEW PATIENT INFORMATIONNAME: ____AGE: ___ DATE: Referring Medical Provider: _____________ Self Referral: (if so, circle)Primary Care Physician:____________________Are you: □Male □Female□Right handed□Left handed □AmbidextrousCHIEF COMPLAINTReason for visit/Primary symptom:Location of your pain: Briefly describe your current symptoms: Does your pain refer to any other areas of your body ? (describe)____________________ _____________________________________________________________When did your symptoms begin? : ____How did your symptoms begin?: Circle the number that corresponds to the severity of your pain on a scale of 0-10. “0” means no pain and “10” is the worst pain you can imagine. At its worst: 012345678910At its best:012345678910Average: 012345678910Today:012345678910Which of the following best describes the character of your pain: Timing:□ Constant□ Intermittent □ Fluctuating□Aching Quality:□ Throbbing□Burning□Superficial□Deep Associated Symptoms:□Tingling/numbnessWhere?_____________________________ __________________□WeaknessWhere?_____________________________What makes your pain worse? What makes your pain better? What activities of daily life do your symptoms interfere with?:________________________________________________________________________________________________________How long/far can you: Sit Stand Walk Have you ever had similar symptoms/injury before? □Yes □No Have you had any loss of bowel or bladder control? □YES □NOPREVIOUS TREATMENTHave you had treatment since your pain began? □Yes □ No Have you had any of the following tests or procedures?:Injections? □ Epidurals□ Facet Injections □ Radiofrequency Neurolysis EMG?□Yes □ NoOther treatments: ________Medical:Dr. Diagnosis given: Medications given Other treatment provided Physical Therapy For Current Area of Pain: □Yes □NoWeeks Completed: In last 6 months? If so, what month: Has it helped? □Yes □NoHome exercise program given? □No □YesChiropractic: □Yes □NoDr. Date of 1st visit Last visit Has it helped? □Yes □NoPAST MEDICAL HISTORY□Diabetes□Lung Disease □Anxiety□Stroke □Alcoholism □Hypertension□Asthma□Depression□Parkinson’s □Hepatitis □High Cholesterol□Ulcers/PUD □Claustrophobia□Polio □Liver disease□Heart Attack □Hyperthyroidism□Chronic pain □ Gout□HIV/AIDS□Glaucoma□Hypothyroidism□Cancer (type?):__________________□ Heart Murmur □Other PAST SURGICAL HISTORYHave you had any surgeries? □Yes □NoIf yes, please list type of surgery and approximate date: CURRENT MEDICATIONS:NAMEDOSAGEHOW OFTEN PER DAY?MEDICATION ALLERGIES □Yes□No If yes, please list:NameReactionAre you allergic or had any reaction to iodine, shellfish, IVP dye, or contrast media? □YES □ NOSOCIAL HISTORY□Single□Married□Divorced□Widowed□”Living together”□SeparatedNumber of children: Ages: ______ ______ ______ ______ ______ ______Do you smoke? □Yes □NoHow much? Previous Smoker? □Yes □NoWhen stopped? Do you drink alcohol? □Yes □No How much? Do you use recreational drugs?□Yes □No What type/how often? Are you currently employed? □Yes □No If yes, type of job SLEEP HISTORYDoes it take you longer than 30 minutes to fall asleep? □Yes □NoDoes pain disrupt your sleep? □Yes □NoFAMILY HISTORYPlease check box for any medical condition that a blood relative has a history of:□Diabetes□Lung Disease □Anxiety□Stroke □Alcoholism □Hypertension□Asthma□Depression□Parkinson’s □Hepatitis □High Cholesterol□Stomach Ulcers □Heart Attack □Thyroid Disease□Chronic pain □Cancer □Arthritis □Other REVIEW OF SYSTEMS: Please mark those items which you CURRENTLY EXPERIENCE:GENERAL□Fever□Weight loss□Weight gain □Fatigue□Chills□Weakness DERMATOLOGIC□Jaundice□Itching□Rash□Lesions□Easy bruisingHEAD/HEARING& VISION□Trauma□Headaches□Dizziness□Blurry vision□Blindness□Changes/loss□Double visionPULMONARY□Shortness of breath□Wheezing □Cough□Coughing up bloodCARDIOVASCULAR□Chest pain□Leg swelling□Racing heartGASTROINTESTINAL□Abdominal pain□Bloody stool□Nausea □Vomiting□Diarrhea □Black, tarry stool □Incontinence of bowels □Heartburn□ConstipationGENITOURINARY□Pregnant (currently)□Pain/burning on urination □Painful menstruation □Blood in urine□Incontinence□Venereal disease□Urgency/frequency with urinationMUSCULOSKELETAL□Joint pain□Joint swellingNEUROLOGICAL Numbness Tingling Pain with light touchPSYCHOLOGICAL Sadness Anxiety Depression Mark on the areas on your body where you feel the described sensations. Use the symbols listed. Mark areas of radiating pain or numbness as well. Include all affected areas.NumbnessTinglingBurningStabbing/SharpAching Cramping NNN TTT BBB SSS AAA CCC R L L R 193501151103700364437626573400536149842904055915932730100 DATE: ________________ PRIMARY LANGUAGE SPOKEN: ___________________________________________ PATIENT NAME: _________________________________________________ Nick Name: ______________________ (Last) (First) (Middle) CHECK ONE: SEX: M______ F_____ CHECK ONE: MARRIED_____ SINGLE_____ WIDOWED_____ DIVORCED_____ RACE: _________________________________________________DATE OF BIRTH: ___________________________ SOCIAL SECURITY: ____________________________ PATIENT’S LOCAL ADDRESS: _____________________________________________________________________________ (Street) (City) (Zip) PERMANENT ADDRESS (IF DIFFERENT): ________________________________________________________________________________________________________________ HOME TELEPHONE #: (_______) _________________________ CELL #: (______) _______________________________ EMAIL: ________________________________________________________________________________________________________ EMPLOYED BY: ___________________________________________ OCCUPATION: __________________________________ WORK # (______) _______________________________ Work ADDRESS: ______________________________________________________________________________________________EMERGENCY CONTACT: ______________________________________ RELATIONSHIP: ___________________________ PHONE #: (______) _____________________________PRIMARY PHARMACY: ____________________________ PHONE #: (_____) ___________________ LOCATION: ___________________________________________________________________________________________________ PRIMARY CARE PHYSICIAN: _____________________________________________________________________________CHECK ONE: ILLNESS/INJURY RELATED TO: WORK ____ AUTO ____ OTHER ____ DATE OF INCIDENT: _______________ **Failure to disclose all insurance information could result in patient being responsible for balance** INSURANCE INFORMATION NAME OF PRIMARY INSURANCE COMPANY: ____________________________ HMO____ PPO ____ POS ____ If WC or Personal Injury Adjuster Name and Phone: ___________________________________________ POLICY/ID#_______________________________________________ NAME OF SECONDARY INSURANCE COMPANY: ___________________________HMO_____PPO_____POS____POLICY/ID#________________________________________________ADDITIONAL INSURANCE COMPANY: _____________________________________HMO____PPO____POS____POLICY/ID#________________________________________________*PLEASE GIVE FRONT DESK ALL INSURANCE CARDS AND DRIVERS LICENSERedding Spine & Sports Medicine Financial & Office PoliciesAuthorization for Medical Release of Information:A form is attached in which you may allow family members and friends access to your medical information. Please fill this out if you would like anyone to have access to your information or participate in your care. Consent for Medical Treatment:I hereby authorize Redding Spine and Sports Medicine and all persons acting as agents thereof, as well as all medical personnel to whom I am referred, to furnish all forms of reasonable diagnostic, preventive, therapeutic and medical treatment to me.___________________________________SignatureMissed Appointments:Our office will try to do reminder calls as a courtesy but patients are ultimately responsible for keeping an appointment. 24 hours notice is required to reschedule or cancel a scheduled appointment. Our office receives referrals for many more patients than we are able to accommodate and we keep a waiting list of patients who are trying to be seen sooner. Please be advised that it is our office policy to no longer see patients who repeatedly miss scheduled appointments. A missed appointment fee of $50 may be applied (if allowed by your insurance carrier) if an appointment is missed after one warning is given. We understand unusual circumstances may arise. In order for our physicians to see patients in a timely manner your help in arriving promptly for your appointment is required. If you are late, our office may reschedule your appointment to a new date and time. We understand your time is valuable and will do our best to see you in a timely manner. Please be aware that sometimes certain situations and emergencies can occur and cause your provider to run late. Please be patient in these circumstances. ________(Initials)Payment and Insurance Policy:Payment is expected at time of service. Your co-pay, coinsurance, and/or deductible is due upon arrival for your visit. For your convenience we accept checks, cash, Visa, MasterCard or American Express as forms of payment. You will be responsible for payment of any remaining balances after insurance is billed. We will require a scan of your insurance card and we will bill your insurance company for you. For those plans that are not contracted with our office we will submit claims to your carrier as a courtesy. Any deductible, coinsurance or non-covered services will be your responsibility. Monthly statements will be sent to collect those balances. Please inform our staff immediately of any insurance, address or phone number changes.________(Initials)Non-Covered Service Policy:Certain services performed by our office are NOT COVERED by all insurance plans. We suggest you contact your insurance carrier to verify your benefits and understand when any non-covered services will be your financial responsibility as payment will be required prior to your appointment. Our office will try to notify you of a non-covered service if we are aware. Medicare requires a signature on an Advanced Beneficiary Notice [ABN] for non-covered services.________(Initials)Delinquent Accounts Policy:Delinquent accounts may be reported to our collection agency following normal collection procedures. If an account is reported to our collection agency a collection fee of 25% will be added to any outstanding balance. If a balance is over 61 days late, a 1.5% monthly interest fee will be added to the outstanding balance. Please inform our billing staff if you know your payment will be late in arriving or if payment arrangements are needed. Our office charges a $25.00 fee for all accounts closed, stop payments or checks returned for non-sufficient funds.________(Initials)Medical Records/Forms:Should you request a copy of your medical records, please allow our office 7-10 business days for completion. There may be a fee for obtaining them, depending on the volume of medical records requested. The fee for medical records is .25 per page for anything beyond 10 pages. Should you request our office to complete forms on your behalf for disability, work status, jury duty, FMLA, etc., there will be a charge of $25.00 per form. Payment of this charge is expected at time of completion.________(Initials)Referrals & Authorizations:If a referral is required by your insurance carrier you will be asked to obtain the referral prior to your appointment. If no referral exists on file or your referral has not been received, your appointment may be cancelled. Our office will obtain authorization for your procedure prior to scheduling your appointment. We suggest you contact your insurance carrier to verify your coverage, benefits and preauthorization requirements prior to having any procedures performed. Claims are paid based on medical necessity. Please be aware authorizations and referrals are not a guarantee of payment._________(Initials)Worker’s Compensation:Our office will require you to inform us of any changes regarding your workers compensation claim. The following information is required: Adjustors Name, claim status, (litigation, supportive care, claim closed, new injury), DOI, carrier, claim number and claims address. Please have this information available prior to your appointment time._________(Initials)Please sign below to verify that you have reviewed and will follow the above office policies:________________________________(Patient/Guarantor Printed Name)________________________________Date___________(Patient/Guarantor Signature)Acknowledgment of Receipt of Privacy NoticeI acknowledge that I have been offered and/or received a copy of the office’s Notice of the Privacy Practices.This handout will be available at the time of your office visit if you have received your paperwork by mail or online.Patient or legally authorized individual signature DatePrinted Name if signed on behalf of the patientDateRelationship to patientPersonal Representative Authorization For Medical Release FormI authorize this facility to speak to the following family members or my personal representative regarding:All medical information, including but not limited to records pertaining to examinations, treatments, consultations, billing records, radiological studies and reports, history, physical findings, laboratory findings, admissions and discharge reports, diagnosis, prognosis and records, nursing and physicians notes and any other non-medical information in my file.Only the following types of information:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________The above medical information may only be released to the following persons:Family member/representative nameRelationship_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________I understand that I may terminate this medical authorization form. I must notify this facility in writing regarding termination and effective date.This authorization to remain valid (check one)Until revoked in writingUntil _____________________________, 20______ I know that I am entitled to receive a copy of this agreementName_________________________________________________________________________________Signature______________________________________________________________________________Signed this __________________ day of ____________________________, 20______________ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download