PDF - Seattle Pain Centers

PATIENT INFORMATION FORM
Date: ______/______/______
PATIENT INFORMATION
Last Name: _____________________________First Name: ____________________________Middle Initial: _____Sex: M
F
Date of Birth: _______/_______/_______ Social Security #:________-______-________ Drivers Lic #:______________________
Address: _________________________________City: ____________________________State: ___________ Zip: ____________
Home #: _________________________ Cell #: _________________________ Marital Status: _____________________________
REFERRAL INFORMATION
Referred By: ____________________________________________________________ Phone: _____________________________
Address: _________________________________City: ____________________________State: ___________ Zip: ____________
POLICY HOLDER (If different than patient)
Last Name: _____________________________First Name: ____________________________Middle Initial: _____Sex: M
F
Date of Birth: _______/_______/_______ Social Security #:________-______-________ Drivers Lic #:______________________
Address: ______________________________________Home #: ________________________ Cell #: _______________________
Name of Employer: __________________________________________________ Phone: _________________________________
INSURANCE INFORMATION
Primary Insurance Plan: ___________________________________ Policy Holders Name: _______________________________
ID #: ________________________________ Group #:_____________________________ Phone: __________________________
Secondary Insurance Plan: _________________________________Policy Holders Name: ________________________________
ID #: ________________________________ Group #:______________________________ Phone: _________________________
EMPLOYER INFORMATION
Employer: ______________________________________________________ Phone: _____________________________________
Address: _________________________________City: ____________________________State: ___________ Zip: ____________
EMERGENCY CONTACT INFORMATION
Name: ____________________________________ Phone: _________________ Relationship to patient: ____________________
ATTORNEY INFORMATION
Name: _______________________________________________________ Phone:________________________________________
Address: _________________________________City: ____________________________State: ___________ Zip: ____________
Injury / Illness Date: ______/_______/_______ Auto? _____________ Other Accident: __________________________________
LIEN - Fill out below if L&I or PI / Auto Insurance (If you have medical coverage)
Insurance: _____________________________________________________________ Phone: ______________________________
Address: _________________________________City: ____________________________State: ___________ Zip: ____________
Claim Adjuster: __________________________________________ Claim #:___________________________________________
Policy Holder: _______________________________________________________________________________________________
HIPAA INFORMATION: Instructions for the office when returning phone calls or reminding you about your appointments.
I authorize the clinic to contact me at: Home
Work
Cell
and may leave messages at: Home
I authorize the clinic to leave detailed messages about appointments/phone calls: YES
Work
Cell
NO
If you prefer us to leave messages with a specific individual, please list them below:
1. _______________________________ 2. ________________________________ 3. ______________________________________
Patient (or Parent/Guardian) Signature ____________________________________________ Date:______________
PAIN HISTORY
REFERRED BY:
PATIENT NAME:
_____________________________________
___________________ DATE OF BIRTH: ___________________
TODAY’S DATE: ________________
Physician Notes: (Physician use only)
Chief Complaint:_________________________________________________
PAIN COMPLAINTS (List your pain and their intensities)
PAIN STARTED on DATE:
_______________________
1.
mild
moderate
_______________________
2.
mild
moderate
mild
moderate
mild
moderate
mild
ABOUT YOUR PAIN
TIMING
DESCRIPTION
moderate










OTHER
 after heavy lifting

severe
Constant
Comes and goes
Frequent
Worse in am
Worse in pm
Began <6 mo ago
Began < 1 yr ago
Began 1-2yrs ago
Began 2-3 yrs ago
Began 3-5 yrs ago
Began >5 yrs ago
Worsening
Stable
Improving
Dull
Heavy

Pressure

Sharp

Stabbing

Electrical

Pins and Needles

Numbness

Burning

Throbbing

Pounding

Aching

Radiates to
______________
OTHER:


© 2009 SEATTLE PAIN CENTER
severe
INCREASED BY
Activity

Walking

Standing

Sitting

Twisting

Lifting

Reaching

Rising from a chair

Walking DOWN stairs

Walking UP stairs

Coughing

Sneezing

Defecating

Intercourse

Cold

Stress
OTHER:
✔


severe
 after falling
_______________________
5.

 due to Auto Accident
_______________________
4.

 due to Job Injury
 on its own
severe
_______________________
3.

severe
________________________

 suddenly
 gradually
DECREASED BY









Activity
Rest
Sleeping
Lying still
Walking
Standing
Sitting
Medications
Injections
Heat

TENS

Acupuncture
OTHER:

IN THE PAST WEEK
Average Pain: _______(0-10)
Pain at Worst: _______(0-10)
Pain at Best: _______(0-10)
0 = No pain
10 = Unbearable pain
ASSOCIATED WITH
Urinary incontinence
Fecal incontinence

New onset weakness
in __________________
OTHER:


Page 1 of 5
PAIN HISTORY
FOR HEADACHES
PATIENT NAME:
_____________________________________
ASSOCIATED WITH
HOW OFTEN?
 daily
 weekly
 monthly
 seasonal
 several times a day
 several times a week
 several times a month
 several months at a time
Typically Lasting:
 minutes
 hours
 days
 light/sound sensitivity
 nausea/vomiting
 weakness in _________________________
 visual disturbances
 seizures
 passing out
 loss of bowel/bladder function
 menstruation
PATTERN
 entire head
 head and neck
 left-sided
 right-sided
 back of head
 temples
 in/around the eyes
 radiates to
_________________________
DIAGNOSTIC STUDIES
Dates
MRI

Places
_____________
Results (Physician Notes)
_________________________
CT

_____________
_________________________
X-rays

_____________
_________________________
Bone scan

_____________
_________________________
Myelogram

_____________
_________________________
EMG/NCV

_____________
_________________________
OTHER

_____________
_________________________
THERAPIES TRIED
MEDICATIONS TRIED
OPIOIDS TRIED (and COMPLICATIONS?)


Physical therapy
 NSAIDS
 helpful  not helpful

TENS
 Lidoderm
 helpful  not helpful

Epidural injections
 Flector
 helpful  not helpful

Trigger Point Injections
 Gabapentin
 helpful  not helpful

Other injections
 Antidepressants  helpful  not helpful

Pain Pump
 Muscle Relaxant  helpful  not helpful

Spinal Cord Stimulation
OTHER:

Medications

OTHER:
Vicodin
__________________________

Darvocet
__________________________

Percocet
__________________________

Dilaudid
__________________________

Morphine
__________________________

Oxycodone
__________________________

Oxycontin
__________________________

Methadone
__________________________
© 2009 SEATTLE PAIN CENTER
Page 2 of 5
PAIN HISTORY
PATIENT NAME:
_____________________________________

Duragesic
__________________________

Actiq
__________________________

Fentora
__________________________

Opana
__________________________
OTHER:
PAIN MEDICATIONS
OTHER MEDICATIONS (current medications)
ALLERGIES
© 2009 SEATTLE PAIN CENTER
Page 3 of 5
PAIN HISTORY
PATIENT NAME:
_____________________________________
PAST MEDICAL HISTORY
CARDIOVASCULAR

Pacemaker

Coronary Artery Disease

Valve-disease

Hypertension

Irregular heartbeats
LUNG DISEASE

Asthma

Emphysema

Shortness of breath
BLEEDING DISORDERS

Yes

No
THYROID DISEASE

Yes

No
ARTHRITIS

Yes

No
LIVER DISEASE

Cirrhosis

Hepatitis C

Hepatitis B

Hepatitis A
KIDNEY DISEASE

Stones

Dialysis

Kidney problems
DIABETES

Insulin

Medications

Diet
CANCER
Type:_______________________
OTHER
CONDITIONS (check conditions you have or have had in the past)












AIDS
Alcoholism
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorders
Breast Lump
Bronchitis
Bulimia
Cancer












Chemical Dependency
Diabetes
Emphysema
Epilepsy
Glaucoma
Goiter
Gonorrhea
Gout
Heart Disease
Hepatitis
Hernia
Herpes
High Cholesterol
HIV Positive
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Mononucleosis
Multiple Sclerosis
Mumps
Pacemaker
Pneumonia
Polio
























Prostate Problems
Psychiatric Care
Rheumatic Fever
Shingles
Stroke
Suicide Attempt
Thyroid Problems
Tonsillitis
Tuberculosis
Typhoid Fever
Ulcers
Venereal Disease
PAST SURGICAL HISTORY
Year
Surgery
Surgeon/Complications
PSYCHOSOCIAL HISTORY
MARITAL STATUS
 single
 married
 divorced  widowed
 live alone
HABITS

Smoking ___ Packs/day

Alcohol ____ Amount

Medication Abuse

Recreational Drugs
_____________________

Drug Rehab
PERSONAL ABUSE HISTORY
 sexual abuse
 physical abuse
 emotional abuse
WORK HISTORY
Occupation:___________________
 Currently working
 Not working
Are you pregnant? Yes  No
Date Last worked?__________
DISABILITY:

Seeking

Already rated

Medicare
Date of last menstrual period?
______________________________
© 2009 SEATTLE PAIN CENTER
FAMILY HISTORY
 Diabetes
 Cancer
 Heart disease
 Hypertension
 Stroke
 Arthritis
 Back Problems
OTHER:
Page 4 of 5
PAIN HISTORY
REVIEW OF SYSTEMS
GENERAL

Weight loss

Weight gain

Fatigue

Fever
SKIN

Rash

Color changes

Redness

Itching

Swelling
HEMATOLOGY

Bleeding

Blood Clots
HEENT

Vision Loss

Double vision

Glasses

Eye pain

Hearing Loss

Dizziness

Tooth/gum pain
PATIENT NAME:
_____________________________________
CARDIOVASCULAR

High Blood Pressure

Chest Pain on Exertion

Irregular Heart Beat

Murmur

Shortness of Breath
RESPIRATORY

Chronic cough

Coughing up blood
GASTROINTESTINAL

Nausea/Vomiting

Heartburn

Constipation

Diarrhea

Bloody Stools

Black Tarry Stools

Abdominal Pain

Trouble Swallowing
GENITOURINARY

Bloody Urine

Urgency/Incontinence

Pain with Urination
MUSCULOSKELETAL

Joint Pain

Stiffness

Limp

Spasms

Muscle Pain

Limited Movement
PSYCHOLOGICAL

Active Suicidal Thoughts

Depression

Anxiety

Sleeping Problems
NEUROLOGICAL

Seizures

Weakness in _____________

Numbness in _____________

Passing Out

Facial Pain

Headaches
ENDOCRINE

Excessive Sweating

Excessive Thirst

Always Cold

Always Hot
I certify that the above information is correct to the best of my knowledge. I will not hold my
doctor or any members of his/her staff responsible for any errors or omissions that I may
have made in the completion of this form.
__________________________________________________
Patient Signature
__________________________
Date
__________________________________________________
Witness
__________________________
Date
© 2009 SEATTLE PAIN CENTER
Page 5 of 5
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY. NOTICE OF PRIVACY PRACTICES PURSUANT TO 45 C.F.R. S
164.520
1. Our Duties
We are required by law to maintain the privacy of your Protected Health Information (“Protected
Health Information”). We must also provide you with notice of our legal duties and privacy practices
with respect to Protected Health Information. We are required to abide by the terms of our Notice of
Privacy Practices currently in effect. However, we reserve the right to change our privacy practices in
regard to Protected Health Information and make new privacy policies effective for all Protected Health
Information that we maintain. We will provide you with a copy of any current privacy policy upon your
written request, addressed to our Privacy Officer, at our current address.
2. Your Complaints
You may complain to us and to the Secretary of the Department of Health and Human Services if you
believe that your privacy rights have been violated. You may file a complaint with us by sending a
certified letter addressed to “Privacy Officer” at our current address, stating what Protected Health
Information you believe has been used or disclosed improperly. You will not be retaliated against for
making a complaint. For further information you may contact our Privacy Officer, at telephone number
212-604-1332.
3. Description and Examples of Uses and Disclosures of Protected Health Information
Here are some examples of how we may use or disclose your Protected Health Information. In connection
with treatment, we will, for example, allow a physician associated with us to use your medical history,
symptoms, injuries or diseases to treat your current condition. In connection with payment, we will,
for example, send your Protected Health Information to your insurer or to a federal program, such as
Medicare, that pays for your treatment. This allows us to obtain payment for the services we rendered
on your behalf. In connection with health care operations, we will, for example, allow our auditors,
consultants, or attorneys’ access to your Protected Health Information to determine if we billed you
accurately for the services we provided to you.
4. Uses and Disclosures Which Require Your Written Authorization
Uses and disclosures other than those involving treatment, payment, and health care operations, as well
as those described in the following sections of this Notice, will only be made by obtaining a written
authorization from you. You may revoke this authorization in writing at any time, except to the extent that
we have taken action in reliance upon your authorization.
5. Uses and Disclosures Not Requiring Your Written Authorization
The privacy regulations give us the right to use and disclose your Protected Health Information if: (I)
you are an inmate in a correctional institution; (ii) we have a direct or indirect treatment relationship with
you, (iii) we are so required or authorized by law. The purposes for which we might use your Protected
Health Information would be to carry out treatment, payment, and health care operations similar to those
described in Paragraph 1.
6. Uses of Protected Health Information to Contact You
We may use your Protected Health Information to contact you regarding appointment reminders or to
contact you with information about treatment alternatives or other health-related benefits and services
that, in our opinion, may be of interest to you. We may use your Protected Health Information to contact
you in an effort to raise funds for our operations.
7. Disclosures of Protected Health Information for Billing Purposes
We may disclose your billing information to any person that calls our billing staff or agents with billing
questions after we verify the identity of the person by requesting information such as your social security
number or health plan number.
8. Disclosures for Directory and Notification Purposes
If you are incapacitated or not present at the time, we may disclose your Protected Health Information
(a) for use in a facility directory, (b) to notify family or other appropriate persons of your location or
condition, and (c) to inform family, friends or caregivers of information relevant to their involvement
in your care or payment for your treatment. If you are present and not incapacitated, we will make the
above disclosures, as well as disclose any other information to anyone you have identified, only upon
your signed consent, your verbal agreement, or the reasonable belief that you would not object to such
disclosure(s).
9. Individual Rights
(i) You may request us to restrict the uses and disclosures of your Protected Health Information, but we
do not have to agree to your request. (ii) You have the right to request that we communicate with you
regarding your Protected Health Information in a confidential manner or pursuant to an alternative means,
such as by a sealed envelope rather than a postcard, or by communicating to a specific phone number,
or by sending mail to a specific address. We are required to accommodate all reasonable requests in this
regard. (iii) You have the right to request that you be allowed to inspect and copy your Protected Health
Information as long as it is kept as a designated record set, and as long as you pay in advance for the
administrative time and costs to make arrangements to have the records inspected and copied. Certain
records are exempt from inspection and cannot be inspected or copied, so each request will be reviewed
in accordance with the standards published in 45 C.F.R. S 164.524. (iv) You have the right to amend
your Protected Health Information for as long as the Protected Health Information is maintained in the
designated record set. We may deny your request for an amendment if the Protected Health Information
was not created by us, or is not part of the designated record set, or would not be available for inspection
as described under section 45 C.F.R. S 164.524, or if the Protected Health Information is already accurate
and complete without regard to the amendment. (v) You have the right to request, and thereafter receive,
an accounting of the disclosures of your Protected Health Information for six years before the date on
which you request the accounting.An exception to this accounting are those disclosures not allowed by
law pursuant to section 164.528. Each request for an accounting will be reviewed pursuant to the rules of
section 164.528. (vi) You also have a right to receive a copy of this Notice upon request.
10. Effective Date
The effective date of this Notice is January 01, 2008.
Signature of Patient or Authorized Representative:
___________________________________________________________________
Print Name _________________________________________________________
Relationship: _________________________________ Date: _________________
Financial Policy
Insurance Payment:
• Your insurance card and photo I.D are required at the time of each appointment.
• Read and understand your insurance policy. Your policy is a contract between you and
the insurance carrier. Read it, understand it, and ask questions. Your insurance does not
automatically cover everything. Even different polices from the same insurance company
can have different requirements. It is YOUR responsibility to know what your policy
covers and what it does not, and also, whether you need referrals or primary care
physician listed.
Non-Insurance Payment:
• For those patients without insurance, payment is required in full at the time of service.
Upon request, we will be happy to provide you with an estimate of the cost for specific
services before your appointment.
• We accept cash and major credit cards.
Co-Pays:
• Co-payment
payment is to be paid at the time of service. If payment is not made within 48 hours
and a bill is sent out, there is a $10 surcharge added to the visit.
Missed Appointment:
appointment, you need to call at least Twenty-Four
Twenty
(24)
• If you cannot attend a scheduled appointment
hours in advance to notify our office. Patients who fail to inform the office of the above
or fail to show for a scheduled appointment
appointment, they will be charged
ed a $50 fee. This charge
will be collected at the time of your next scheduled appointment and / or will be billed to
you directly. We will not bill your insurance company for missed appointments.
Tardiness:
• If you are more than twenty minutes late to a scheduled appointment, a $50 late fee will
be charged. This charge will be collected at the time of your next appointment and / or
will be billed to you directly. We will not bill your insurance company for late fees.
Payment Arrangement:
cumstances, payment arrangements may be made with our billing
• Under special circumstances,
department. Payments must be paid on a monthly basis. Payment arrangements apply to
the existing balance only. All subsequent services must be paid according to office
policy.
payment will result in a delinquent status and the special
• Missed payments or non-payment
arrangement may be terminated. Any account(s) going into default will be sent to
collections without further notice!
_____________________________
____________________________________
Print Name
____________________________________
_____________________________
Signature & Date
Opioid Treatment Agreement
Opioid (narcotic) treatment for chronic pain is used to reduce pain and improve what you’re able to do
each day.
Along with opioid treatment, other medical care may be prescribed to help improve your ability to do
daily activities. This may include exercise, use of non-narcotic analgesics, physical therapy, psychological
counseling or other therapies or treatment.
I, __________________________, understand the compliance with the following guidelines is important
in continuing pain treatment with the Seattle Pain Center. I understand that I have the following
responsibilities and agree to adhere to all of the following rules while I am under the care of Seattle Pain
Center:
1. I will take medications as prescribed.
2. I will not increase or decrease without the approval of my physician.
3. I will not obtain medications from several physicians, but my physician only. (Under certain
circumstances, if I obtain any additional narcotic from other physicians such as primary care
physician or emergency room physician, then I will immediately notify Seattle Pain Center.)
4. I will not share the medication with anyone including family members.
5. I will not sell the medication.
6. I will not get replacement from any lost or stolen medication regardless of the circumstance.
7. I will not get early refills.
8. I will notify if I use alcohol or other illicit drugs along with pain medication.
9. I agree to periodic random drug screening tests.
10. I agree to periodic random pill counts.
11. I agree to participate in adjunctive pain management programs such as: psychological aspects of
pain management, counseling therapy, stress reduction program, pain coping skills, behavioral
modification, biofeedback, and physical therapy if recommended by the physician.
12. I agree to taper off from Opioid pain medication if I feel there is no improvement in pain control
or daily functional ability with medication.
13. I will not request prescription refills when the clinic is closed after hours or on weekends.
14. If I am pregnant or intend to get pregnant, I am required to notify Seattle Pain Center immediately
to discuss tapering off Opioid and/or benzodiazepam-type medications that could potentially
harm the fetus. I understand that failure to do so may result in discharge from the clinic. I will not
hold the clinic responsible for any harm that may occur to me and/or my unborn.
I, __________________________, understand that this physician may stop prescribing the medication
or change the treatment plan if I failed to follow the above recommendations.
I have read this document, understand and have had all my questions answered satisfactorily.
I consent to the use of Opioids to help control my pain and I understand that my treatment with
Opioids I will be carried out as described above.
_______________________________________
Print Patient Name
_______________________________________
Patient Signature & Date
_______________________________________
Print Witness Name
_______________________________________
Witness Signature & Date
_______________________________________
Print Physician Name
_______________________________________
Physician Signature & Date
Patient Approved Contact
PATIENT NAME (please print): _______________________________ Date of Birth: ____/____/____
NOT DESIGNATING ANYONE AT THIS TIME Initials: _______ Today’s Date: ____/____/____
PLEASE NOTE: In authorizing these individuals we will also assume that there are no limitations in
communications regarding the patient unless otherwise noted. If any individual other than those listed below
contacts Seattle Pain Center regarding the above named patient’s personal health information, he or she will be
referred back to the patient.
CONTACT 1: (please print)
Name ___________________________________ Relationship to patient _____________________
Contact Number (______) _______-_________ Emergency Response Person: YES / NO Limitations
in communications: ______________________________________________________
________________________________________________________________________________
CONTACT 2: (please print)
Name ___________________________________ Relationship to patient _____________________
Contact Number (______) _______-_________ Emergency Response Person: YES / NO Limitations
in communications: ______________________________________________________
________________________________________________________________________________
CONTACT 3: (please print)
Name ___________________________________ Relationship to patient _____________________
Contact Number (______) _______-_________ Emergency Response Person: YES / NO Limitations
in communications: ______________________________________________________
________________________________________________________________________________
SIGNATURE (Patient/Representative) X_____________________ Today’s Date: _____/_____/_____
IF signed by Representative, describe authority to act on behalf of patient:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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