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New Patient Paperwork Online

New Patient Paperwork Online

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Published by garretrock

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Published by: garretrock on Jan 09, 2009
Copyright:Attribution Non-commercial

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09/14/2012

 
Pain Partners, MD
INFORMATION/APPLICATION FOR CARE
New Patient Intake Forms
   W  e   l  c  o  m  e   t  o   P  a   i  n   P  a  r   t  n  e  r  s ,   M   D   ! 
   O   u   r   B   a   c    k   a   n    d   S   p    i   n   e   D    i  v    i   s    i   o   n    i   s   t    h   e   m   o   s   t   c   o   m   p   r   e    h   e   n   s    i  v   e    b   a   c    k   p   a    i   n   c   e   n   t   e   r    i   n   C   o    l   o   r   a    d   o .   O   u   r    i   n   t   e   g   r   a   t   e    d   a   p   p   r   o   a   c    h    h   a   s   r   e   s   u    l   t   e    d    i   n   u   s    b   e    i   n   g   r   a   t   e    d   a   s   o   n   e   o    f   t    h   e   t   o   p    b   a   c    k   p   a    i   n   c   e   n   t   e   r   s .   W   e   a   r   e   e  x   c    i   t   e    d   t   o    h   a  v   e   t    h   e   o   p   p   o   r   t   u   n    i   t  y   t   o   e   a   r   n  y   o   u   r   t   r   u   s   t   a   n    d    d   e    l    i  v   e   r  y   o   u   t    h   e    b   e   s   t   s   e   r  v    i   c   e    i   n   t    h   e    i   n    d   u   s   t   r  y . 
 
Pain Partners, MDBack and Spine CarePatient Information
The following information is needed in order to better serve you. Please complete all questions. If you need help please ask the receptionist. PLEASE PRINT.
 Today’s Date __________  Name __________________________________ Home Phone ______________ Work Phone ______________ Address ________________________________ City ___________________ State ________ Zip __________ Age _____ Birth date ______________________Marital Status: S M W D Number of Children _________ Your Employer ______________________________ Occupation ____________________________________ Insurance Company ___________________________________ Your Social Security # ___________________ Primary Care Physician:____________________________________Phone #:___________________________ Primary Care Physician Address:________________________City:______________State:____Zip:_________ Do you have Medicare? Yes ____ No ____  Name of Spouse or Parent ___________________________________ Their Birth date ___________________ Referred to our office by: _______________________Your Email:____________________________________ How payment will be made: __________ Cash __________ Check __________ Credit Card_________ Is your condition due to an accident? Yes _____ No _____ Date of accident?____________________ Type of accident? Auto _____ Work/On Job _____ At Home _____ Other _____________________ Have you ever been in an auto accident? Past Year ____ Past 5 Years ____ Over 5 Years _____Never ______ I (we) agree to pay for services rendered to the above mentioned patient as the charge is incurred. I understandand agree that health & accident insurance policies are an arrangement between an insurance carrier and myself and that I am personally responsible for payment of any and all services not covered. I also understand that if Isuspend or terminate my care and treatment, any fee for professional services rendered me will be immediatelydue and payable.Patient’s Signature ___________________________________________ Date _______________________ Or Guardian Signature ________________________________________ Date _______________________  Notice to our new patients: Full payment of the “patient responsibility amount” for services rendered is due atthe end of each visit. If for any reason this request cannot be met, arrangements should be made in advance before seeing the doctor. _____Initial
In consideration of your undertaking to care for me, I agree to the following:1.I authorize Colorado Back and Spine Center, P.C. to release any information you deemappropriate concerning my physical condition to any insurance company, attorney, or adjusterin order to process any claim for reimbursement of charges I incur.2.I further agree that this authorization is irrevocable and ongoing until all monies owed arepaid in full.3.This authorization will be in continual effort until revoked by both parties. ________________________________________________________________________________ Patient/Insured Signature Date
Pain Partners, MD
2
 
Back and Spine CarePatient Health Questionnaire
Patient Name_______________________________________ Date______________________
1.
Describe your symptoms____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
a.
When
did your symptomsstart?____________________________________________________________________________ b.
How
did your symptomsbegin?____________________________________________________________________________ 
Indicate where you have pain or other symptoms2. How often do you experience your symptoms?
Constantly (76-100% of the day)Frequently (51-75% of the day)Occasionally (26-50% of the day)Intermittently (0-25% of the day)
3. What describes the nature of your symptoms?
Sharp Dull Numb ShootingBurning Tingling Sore Stabbing
4. How are your symptoms changing?
Getting Better Not Changing Getting Worse
5. How bad are your symptoms?
None UnbearableAt its WORST 0 1 2 3 4 5 6 7 8 9 10At its BEST0 1 2 3 4 5 6 7 8 9 10
6. How do your symptoms affect your ability to perform daily activities? (circle one)
Not at all A little bit Moderately Quite a bit Extremely Severe
7. What activity makes your symptoms worse?_____________________________________What activity makes your symptoms better?_____________________________________8. Who have you seen for your symptoms? 
No One Chiropractor Medical Doctor Physical Therapist OtherWhat tests have you had for your symptoms and when were they performed?Circle all that apply X-rays CT Scan MRI Other
9. Have you had similar symptoms in the past?
 Yes No If you have received treatment in the past for the same or similar symptoms, who did you see?Circle all that apply: This office Chiropractor Medical Doctor Physical Therapist Other
10. Are you currently seeing any health care providers for any other condition? Yes NoIf YES, please list provider(s) below:____________________________________________________________________________11. What do you hope to get form your visit/treatment (select all that apply)Reduced symptoms Resume/Increase activity Explanation of condition/treatmentLearn how to take care of this myself How to prevent this from occurring againOther____________________________Patient Signature_________________________________ Date________________________
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