Patient Information



Patient Information

Please fill out legibly.

Referring Doctor: _____________________________________________Office #: ________________________________________________________

●Name: _____________________________________________________ D.O.B: _______________________ SSN #: ____________________________

Address: _____________________________________________________ City: _________________________ State: _______ Zip: ________________

Home Number: _____________________________ Cell Number: ______________________________ Work Number: __________________________

Employer: _________________________________ Occupation: _______________________________

Marital Status: _____________________________ Spouse: ___________________________________ D.O. B.: ________________________________

Emergency Contacts

●Name: ____________________________________ Relation: _________________________________Contact #: _______________________________

●Name: ____________________________________ Relation: _________________________________Contact #: _______________________________

Insurance Information

● Primary Insurance: __________________________________________________________Verify #: _______________________________________

Policy #: __________________________________Group #: _______________________________ Guarantor: ________________________________

PPO NAP HMO EPO POS CHOICE PLUS W/C OTHER: ___________________________________________________

●Secondary Insurance: _________________________________________________________________Verify #: _______________________________

Policy #: __________________________________Group #: _______________________________ Guarantor: ________________________________

PPO NAP HMO EPO POS CHOICE PLUS W/C OTHER: _____________________________________________________

Workman’s Compensation

●D.O.I.: _____________________________________________________ Claim #: ________________________________________________________

Adjustor: _____________________________________________________ Contact #: ______________________________________________________

Insurance Carrier: _____________________________________________ Phone: _________________________________________________________

Address: _____________________________________________________________________________________________________________________

Edward T. Shin, M.D., D.A.B.P.M.

Comprehensive Pain Management

American Society of Anesthesiology and American Board of Pain Medicine

Office) 972-612-0162 Fax (972) 612-0173

ASSIGNMENT OF INSURANCE BENEFITS

The undersigned hereby authorized the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependants, and I will bound by this signature as though the undersigned had personally signed the particular claim.

I ___________________ hereby authorize _____________________ to pay and assign directly

(Name Insured) (Insurance Company)

to Dr. Edward Shin, M.D. all benefits, if any otherwise payable to me for his services as described on the attached forms. I understand that I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when I receive by and paid to Dr. Edward Shin, M.D. will be credited to my account, in accordance with the above assignment. I understand that I am responsible for all charges whether or not paid by insurance.

____________________________ ________________________ (Authorized signature of subscriber) (Date)

Edward T. Shin, M.D., D.A.B.P.M.

Comprehensive Pain Management

American Society of Anesthesiology/ American Board of Pain Medicine

Office) 972-612-0162 Fax) 975-612-0173

Date:_________________________________________

Name: ________________________________________

Age: __________________________________________

Referring Doctor: ______________________________

1. Where is your pain?_________________________________________________________________________________________

2. When did it start? __________________________________________________________________________________________

3. Briefly describe the history of your pain_________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Are you taking Pain medications? Y / N How long have you been on pain medications?_________________________________

5. Have you had any surgery for your pain?________________________________________________________________________

6. When is the pain the worst? Morning Afternoon Night

7. Circle the best descriptions of your pain: Burning Aching Sharp Stabbing Shooting Throbbing

8. What activity makes the pain worse? Standing Sitting Walking Bending Lying down

9. What activity makes your pain better?__________________________________________________________________________

10. Grade your pain from 0 to 10 (zero=no pain/10=worst pain ever): Usual pain_________ Pain w/ activity_________

11. Have you had any of these treatments: Physical therapy / Epidural steroid injections / Facet blocks / Trigger point injections

Narcotic pump implant / Spinal cord stimulator implant / Botox injections / Chiropractic treatments

12. Do you have weakness in your arms? Y/ N If yes, which arm? ___________________________________________________

13. Do you have weakness in your legs? Y/ N If yes, which leg?_____________________________________________________

14. Are there any areas of numbness? Y/ N If yes, where are you numb? ______________________________________________

15. Is your case under Worker’s Compensation? Y/ N If yes, date of injury is____________________________________________

16. Are you involved in any lawsuits concerning your case? Y / N

17. Have you ever had psychiatric counseling? Y / N If yes, when was your last counseling?______________________________

18. Please list all other physicians who are involved in your care______________________________________________________ __________________________________________________________________________________________________________

1

Pain

Past Medical History: (Please circle)

Seizures Strokes Migraines High blood pressure Heart attack Heart failure Atrial fibrillation Low heart beat Fast heat beat Mitral valve prolapse COPD Emphysema Asthma Breast cancer Lung cancer Hepatitis Cirrhosis Pancreatitis Acid Reflux Gastric ulcers Crohn’s disease Anxiety Depression Panic attacks Bipolar disorder Suicide attempt Kidney disease Irritable bowel syndrome Liver disease Diabetes Hypothyroidism Hyperthyroidism Osteoarthritis Rheumatoid arthritis Fibromyalgia

Sleep Apnea Using Aspirin Using Coumadin Multiple sclerosis Drug addiction HIV Head injury

Blood clots Lupus Ulcerative colitis Endometriosis Chronic fatigue syndrome TMJ Blood transfusion

Chronic back pain Chronic neck pain Scoliosis TB Peripheral neuropathy Restless leg syndrome

Other:___________________________________________________________________________________________

Do you have any allergies to any medications? (please circle) Y/ N

If yes, what are your allergies? ________________________________________________________________________

Please list all Major surgeries: Date:

1._____________________________________ ______________________________

2._____________________________________ _______________________________

3._____________________________________ _______________________________

4._____________________________________ _______________________________

5._____________________________________ _______________________________

Name of Medications and their Doses: Frequency: 1._____________________________________ _______________________________

2._____________________________________ _______________________________

3._____________________________________ _______________________________

4._____________________________________ _______________________________

5._____________________________________ _______________________________

6._____________________________________ _______________________________

Pain Clinic

Have you had an MRI? Y/ N If yes, Date of last MRI______________________________________

Have you had an EMG/NCV? Y/ N If yes, Date of last EMG?_______________________________

(Muscle testing and nerve testing)

Have you had an EKG? (Cardiac tracing) Y/ N If yes, Date of last EKG______________________________________

Previous Medications used: (Please circle)

Demerol Dilaudid MS Contin Kadian Avinza Methadone Percocet Percodan Talwin Hydrocodone

Tylenol#3 Tylox Ultram Ultracet Lortab Lorcet Vicodin Oxycontin Oxycodone Duragesic Patch

Actiq Elavil Neurontin Xanax Ativan Valium Ambien Flexeril Soma Zoloft Trazadone

Social History: (Please circle)

Married / Single/ Widowed?

Current or past Occupation_________________________________________________________________________________

Do you collect social security disability or work related disability?__________________________________________________

Do you Smoke? Y/ N If yes, how much do you smoke?________________________________________________________

Do you drink alcohol? Y/ N If yes, how much do you drink?____________________________________________________

Do you have a history of alcohol abuse? Y/ N If yes, have you been through alcohol rehab?___________________________

Do you have a history of drug abuse? Y/ N If yes, what drugs were abused?_______________________________________

Family History: (Please circle)

Mother’s medical history:

Living or Deceased

Age________________

If deceased, cause of death__________________________________________________________________________________

List mother’s medical problems:_____________________________________________________________________________

Father’s medical history:

Living or Deceased

Age________________

If deceased, cause of death__________________________________________________________________________________

List father’s medical problems:______________________________________________________________________________

Are there any family members with a history of alcoholism? Y/ N If yes, who______________________________________

Are there any family members with a history of drug abuse? Y/ N If yes, who______________________________________

3

Pain Clinic

Do you currently suffer from any of these problems? (Please circle)

1. General: fever chills fatigue insomnia

2. Eyes and ears: double vision blurred vision

3. Skin: easy bruising easy bleeding get infections easily

4. Psychiatric: anxiety depression thoughts of suicide attempted suicide

5. Neurologic: headache dizziness tremors vertigo

6. Cardiovascular: chest pain palpitations murmurs

7. Respiratory : cough shortness of breath wheeze

8. Gastrointestinal: abdominal pain constipation diarrhea nausea vomiting

9. Genitourinary: new bladder control problems new bowel control problems

10. Musculoskeletal: muscle diseases joint diseases

11. Endocrine: unexpected weight loss________ or weight gain______________________

Height: _____________________Current Weight: _____________________ Ideal Weight:__________________________

For Physician’s use: Back/ Neck BP/HR:__________________________________

Inspection: lordosis: normal/ decreased khyphosis: +/ -- Scoliosis: +/ --

Palpation:_____________________________________________________________

Range of motion: flexion______________extension___________________________

Motor function:________________________________________________________

Sensory function:_______________________________________________________

Reflexes: Patellar________Achilles__________Biceps_________Triceps__________

Straight leg:____________Hoffman’s__________Inverted Brachioradialis _________

Gait:______________Station:___________________

SI: Palpation______________Pelvic rock________________ Fabere’s____________

Other___________________________________________________________________________________________________________________________

Dianosis:___________________________________________________________________________________________________________________________

Cerical facet(716.98), Sacroiliiac (720.2), DDD-lumbar (722.52), FBSS-cervical (722.81), FBSS-lumbar(722.83), SS-lumbar (724.02), MFPS (729.1),DrugD(304.9)

Plan:

________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I. Narcotic Contract

You have agreed to take narcotic pain medications for your chronic pain. The purpose of this treatment is to reduce your pain and to improve your quality of life.

Risks of Chronic Narcotic Therapy:

Patients who take narcotics on a regular basis can become physically dependent and addicted to these medicines. Over the course of time, many physical and psychological changes may occur. If pain medications are prescribed, Therefore, sudden discontinuation of these medicines may lead to withdrawal. Do not suddenly stop taking your medicines. Addiction is psychological dependence. If you become pregnant, notify your physician as soon as possible.

You must not drive while taking any prescription medications. Do not drive while taking your pain medicines. Do not drink alcohol.

Pain medications may interact with other commonly used medications. If you are taking any antihistamines, tranquilizers, sleep medicines, muscle relaxants (soma, baclofen), MAO inhibitors (phenelzine, nardil, parnate), antidepressants (cymbalta, elavil), anxiety medicines, anticonvulsants (neurontin, tegretol), diuretics (lasix, HCTZ) or other specific medications such as trexan, revia, rifampin, or zidovudine (AZT, retrovir), you may be at increased risk for serious side effects.

Pain medications may cause respiratory depression and other systemic problems. Patients with a history of head injury, increase intracranial pressure, COPD, asthma, pulmonary hypertension, prostate problems, liver disease, kidney disease, gastric problems, intestinal problems, psychiatric problems or Addison’s disease are at an increased risk for serious side effects.

1. Summary of risks of pain medications, muscle relaxants, anticonvulsants, antidepressants, anxiolytics, and sleep medications:

addiction, physical dependence, withdrawal, respiratory depression, nausea, vomiting, constipation, sweating, fatigue, itching, swelling, headache, restlessness, confusion, nightmares, hallucinations, weakness, blurred vision, loss of coordination, fainting,

dizziness, abdominal pain, problems urinating, worsening anxiety, worsening depression, slow heartbeat, low blood pressure, heart attack, strokes, seizures, and even sudden death. __________

2. You must not drive while taking your pain medications, muscle relaxants, anxiety medicines, anti-depressants, or seizure medications. I understand I am not to drive while I am taking any prescription medications.__________

3. You must fill your prescription from the same pharmacy every time. If you receive pain medications from the ER,

provide a copy of the ER visit. Do not receive pain medications from any other physician.

4. You must bring you pain medications with you to every appointment. Pain medications will not be refilled without your

pain medication bottles. No pain medications will be refilled early, after hours or on weekends.

5. If you have side effects from any new medicines, stop taking the medication, and call the office for a follow up visit. Go to the ER if you are having any severe side effects.

6. If your pain medications are stolen, lost or misplaced, please provide a police report or a written letter of explanation signed by you and your closest relative explaining the situation.

Print Name_________________________________ Signature_____________________________ Date________________

II. Informed Consent (Epidural steroid injections, Facet injections, Trigger point injections, Nerve blocks, etc.)

The risk of injury while undergoing any type of injection therapy is very low. Many safeguards are used to maximize our chance of success and lower your chance of injury. Possible side effects from medications used in most injections are swelling, weight gain, hot flashes, mood changes, increased appetite, and allergic reactions. Bleeding, infection, nerve injury, paralysis, pneumothorax, chronic pain, and worsening of the pain are possible complications of any type of surgery or injection treatments.

Patients with diabetes must monitor their serum glucose carefully. Steroid injections may cause large elevations in serum glucose. If your serum glucose rises, you must seek medical attention as soon as possible.

Print Name ________________________________ Signature_____________________________ Date________________

CONSENT TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

1. Patient Consent for the Use and Disclosures of Protected Health Information (“PHI”)

I, the undersigned patient, give my consent to the provider entity and its agents to use or disclose my protected health information (“PHI”) to carry out treatment, payment, or health care personnel including, but not limited to, physicians, certified registered nurses anesthetists, anesthesia assistants, nursing staff, nurse practitioners, physicians assistants, child life specialists, physical therapists, respiratory therapists, X-ray personnel, audiologists, students in each of the above disciplines, and other such entities or persons as deemed related to treatment, payment, and health care operations, as determined in sole discretion of the provider, his/her/practice group, and their respective agents.

2. Permission to Release Medical Records or Providers

If another provider who is involved with treatment, payment, or health care operations relating to me requests my medical records, I consent to release of my entire medical records maintained by the provider to those other providers.

3. Permission to Release Billing Information over the Telephone

I agree, as part of this consent for payment operations, that the provider, its group, and their billing personnel, billing agents, or management company can disclose billing information to any person that calls the provider with billing questions after the provider inquires as to the identity of the calling person and the calling person provides my correct social security number or health plan number.

4. Permission to Call and Leave Voice Messages

I agree that the provider or its agents or representatives may call and leave a voice mail message at y home or other umber I provide them regarding medical appointments, billing or payment issues, or other information related to treatment, payment, or health care operations.

5. Permission to Discuss Protected Health Information with Third Persons

I agree that the provider may discuss my PHI with any person that accompanies me to a visit or is present with me when the provider is present. The provider may rightly assume that if another person is with me, I have no objection to disclosure of my PHI to that person. I also agree the provider may discuss my PHI with any persons that identifies him or herself as active in my mental, physical, emotional, spiritual care, including but not limited family, friends, clergy, and patient advocates. I also agree that the provider, his/her practice group, and their agents may disclose my PHI to employers who arrange and pay, directly or indirectly, for my medical treatment.

6. Permission to Discuss Protected Health Information Regarding Minors

I agree that the provider, his/her practice group, and their agents may discuss my child’s PHI with the person accompanying the child. I agree that the provider may discuss PHI with both natural parents and step parents. I acknowledge that state may grant my child certain privacy rights regarding the child’s PHI, and that I have no right to receive this information.

7. Permission to Discuss Protected Health Information with Public Agencies

I agree the provider, his/her practice group, and their agents may, upon request by the following entities, disclose my PHI to public health agencies, law enforcement, and the FDA.

8. Acknowledge of Receipt of Notice of Private Practices

I acknowledge that I have received from this provider a copy of a separate document, entitles, “Notice of Privacy Practices” which sets forth this provider’s privacy practices and my rights regarding privacy of my PHI.

______________________________ __________________

Patient Signature Date

Edward T. Shin, M.D., D.A.B.P.M.

Comprehensive Pain Management

American Society of Anesthesiology and American Board of Pain Medicine

Office) 972-612-0162 Fax (972) 612-0173

Office hours:

The office is open Monday through Friday, 8:00 A.M. to 5:00P.M.

Schedule your follow up appointment at the end of each clinic visit.

Confirm office location with each appointment.

Emergency Messages

To leave any urgent messages, you may call 214-681-1194.

Someone from our office will return your call within 24 hours to assist you.

For any emergencies please go to the emergency room.

*Please note that this is for emergency purposes only.

Billing and Insurance

Provide a picture ID and insurance information before your evaluation.

Patients who are out of network with their insurance will be billed according to in-network rates.

If you are having problems with hospital bills and anesthesia fees,

we will make every effort to assist you whenever possible.

If you have any questions, please contact our billing department at 972-772-4539.

Payment

Insurance co-pays and deductibles must be paid prior to the time of service.

We no longer take checks more than $100.00 unless they are certified checks.

A fee of $25.00 for returned checks is assessed.

We accept Mastercard and Visa.

Late appointment arrivals

We will make every effort to see you when you arrive.

Please be advised that it may be necessary to reschedule your appointment if you are more than 30 minutes late.

Walk-in visits:

We will make every effort to see you as soon as possible.

Patients with scheduled appointments will be seen first.

If you are experiencing an emergency, please call the office prior to making your emergency visit.

Missed appointment

Please contact our office 24 hours in advance if you are canceling your appointment.

Missed appointments may result in a $35.00 cancellation fee.

I. Narcotic Contract

You have agreed to take narcotic pain medications for your chronic pain. The purpose of this treatment is to reduce your pain and to improve your quality of life.

Risks of Chronic Narcotic Therapy:

Patients who take narcotics on a regular basis can become physically dependent and addicted to these medicines. Over the course of time, many physical and psychological changes may occur. If pain medications are prescribed, Therefore, sudden discontinuation of these medicines may lead to withdrawal. Do not suddenly stop taking your medicines. Addiction is psychological dependence. If you become pregnant, notify your physician as soon as possible.

You must not drive while taking any prescription medications. Do not drive while taking your pain medicines. Do not drink alcohol.

Pain medications may interact with other commonly used medications. If you are taking any antihistamines, tranquilizers, sleep medicines, muscle relaxants (soma, baclofen), MAO inhibitors (phenelzine, nardil, parnate), antidepressants (cymbalta, elavil), anxiety medicines, anticonvulsants (neurontin, tegretol), diuretics (lasix, HCTZ) or other specific medications such as trexan, revia, rifampin, or zidovudine (AZT, retrovir), you may be at increased risk for serious side effects.

Pain medications may cause respiratory depression and other systemic problems. Patients with a history of head injury, increase intracranial pressure, COPD, asthma, pulmonary hypertension, prostate problems, liver disease, kidney disease, gastric problems, intestinal problems, psychiatric problems or Addison’s disease are at an increased risk for serious side effects.

1. Summary of risks of pain medications, muscle relaxants, anticonvulsants, antidepressants, anxiolytics, and sleep medications:

addiction, physical dependence, withdrawal, respiratory depression, nausea, vomiting, constipation, sweating, fatigue, itching, swelling, headache, restlessness, confusion, nightmares, hallucinations, weakness, blurred vision, loss of coordination, fainting,

dizziness, abdominal pain, problems urinating, worsening anxiety, worsening depression, slow heartbeat, low blood pressure, heart attack, strokes, seizures, and even sudden death. __________

2. You must not drive while taking your pain medications, muscle relaxants, anxiety medicines, anti-depressants, or seizure medications. I understand I am not to drive while I am taking any prescription medications.__________

3. You must fill your prescription from the same pharmacy every time. If you receive pain medications from the ER,

provide a copy of the ER visit. Do not receive pain medications from any other physician.

4. You must bring you pain medications with you to every appointment. Pain medications will not be refilled without your

pain medication bottles. No pain medications will be refilled early, after hours or on weekends.

5. If you have side effects from any new medicines, stop taking the medication, and call the office for a follow up visit. Go to the ER if you are having any severe side effects.

6. If your pain medications are stolen, lost or misplaced, please provide a police report or a written letter of explanation signed by you and your closest relative explaining the situation.

Print Name_________________________________ Signature_____________________________ Date________________

II. Informed Consent (Epidural steroid injections, Facet injections, Trigger point injections, Nerve blocks, etc.)

The risk of injury while undergoing any type of injection therapy is very low. Many safeguards are used to maximize our chance of success and lower your chance of injury. Possible side effects from medications used in most injections are swelling, weight gain, hot flashes, mood changes, increased appetite, and allergic reactions. Bleeding, infection, nerve injury, paralysis, pneumothorax, chronic pain, and worsening of the pain are possible complications of any type of surgery or injection treatments.

Patients with diabetes must monitor their serum glucose carefully. Steroid injections may cause large elevations in serum glucose. If your serum glucose rises, you must seek medical attention as soon as possible.

Print Name ________________________________ Signature_____________________________ Date________________

Edward T. Shin, M.D., D.A.B.P.M.

Comprehensive Pain Management

American Society of Anesthesiology and American Board of Pain Medicine

Office) 972-612-0162 Fax (972) 612-0173

I. The following medications must be stopped prior to your procedure:

STOP FOR 7 DAYS STOP FOR 3 DAYS OK TO TAKE

Aspirin Advil Amitriptyline

Anacin Aleve Baclofen

Aggrenox Bextra Hydrocodone

Bufferin Lodine (Etodolac) Gabapentin (Neurontin)

Ticlid Meloxicam Methadone

Calcilean Motrin (Ibuprofen) MS Contin

Coumadin (Warfarin) Mobic Oxycontin

Ecotrin Vicoprofen Prednisone

Exedrine Naprosyn Topamax

Feldene Trilisate Tylenol (Acetaminophen)

Gingo Biloba Voltaren (Arthrotec) Ultram

Garlic Heparin Vicodin

Ginseng Lovenox Xanax

Indocin Daypro Soma

Percodan Lortab

Plavix

Salicilate

II. Preparing for your injection:

1. You must bring SOMEONE TO DRIVE YOU HOME after the procedure. Your stay will be approximately two hours. Someone should stay with you for 8 hours after the procedure.

2. Please arrive one hour before your scheduled procedure time. Wear comfortable clothes.

3. Please bring a picture ID, insurance cards, and your co-pay.

4. If your procedure is in the morning, do not eat or drink anything after midnight.

5. If your procedure is in the afternoon, you may eat breakfast, but you must follow these guidelines:

Do not drink liquids for 6 hours, and do not eat solid food for 8 hours prior to your procedure time. If you eat in the morning, do not eat a heavy meal. Choose something light such as toast, clear soup, or clear liquids. Avoid foods heavy in fat, meats or heavy sauces.

6. If you take medications in the morning for blood pressure, heart disease, lung disease, or any chronic illness, take your medications with a sip of water. Do not drink heavy liquids such as milk or orange juice.

7. Injections are often done in a set of 2 to 3. After your first procedure, you will be given another appointment for your next injection.

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