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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: