Please note you can only have one pharmacy on file, this will be the pharmacy we use to call in any prescriptions from our office.
Rate your pain intensity: On a scale of 1 to 10, with "0" representing no pain, "1" representing a nuisance that would not interfere with daily activities (i.e. toothache) while "10" would be the most severe pain imaginable (suicidal pain, having a baby or pain of a kidney stone), which number would best describe your pain?
Could you please complete this questionnaire? It is designed to give us information as to how your pain has affected your ability to manage in everyday life.
Please answer every section. Mark one box only in each section that most closely describes you today.
How many children have you had? Type a label* children
Who do you live with at home?Type a label*
How far did you get in your education?Type a label* level
Quit smoking for * Years * Packs per day
Social consumption of alcohol* alcoholic beverages/day
Type a label* caffeinated beverages/day
Are you experiencing any of the following symptoms with regularity that is different than what listed before? If so, please check.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
This is your Health Information Privacy Notice from Pain Management Services. Please read it carefully.
Pain Management and each member of the Pain Management staff strongly believe in protecting the confidentiality and security of information we collect about you. This notice refers to Pain Management using the terms "us," "we," or "our."
This notice describes how we protect the personal health information we have about you which relates to your treatment ("Personal Health Information"), and how we may use and disclose this information. Personal Health Information includes individually identifiable information which relates to your past, present or future health, treatment or payment for health care services. This notice also describes your rights with respect to personal health information and how you can exercise those rights.
We are required by law to:
We protect your Personal Health Information from inappropriate use or disclosure. Our employees, and those of companies that help us, are required to comply with our requirements that protect the confidentiality of Personal Health Information. They may look at your Personal Health Information only when there is an appropriate reason to do so.
We will not disclose your Personal Health Information to any other company for their use in marketing their products to you. However, as described below, we will use and disclose Personal Health Information about you for business purposes.
HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected heath information (PHI). The individual is also provided the right to request confidential communications or that a communication of the PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individuals home.
This form is to be used to signify the alternative means for sharing PHI.
WITHOUT THIS INFORMATION YOUR APPT. WILL NEED TO BE RESCHEDULED.