• New Patient Packet

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    Pick a Date
  • Patient Contact Information

  • Patient Home Address

  • Patient Information

  • Primary Care Information

  • Pharmacy Information

  • 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.

  • Insurance Information

  • Medication List

    This must be filled out entirely in order for your doctor to be able to prescribe you any medications.
  • Allergies

  • Please answer the following questions:

  • Please answer the following questions:

  • Please answer the following questions:

  • Please answer the following questions:

  • 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?

  • Please answer the following questions:

  • Please answer the following questions:

  • 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.

  • Past Medical History

    In your past, have you ever had any of the following health problems? (Check all that apply)
  • Past Surgical History

  • Family History

    How is the general health of your family? Please write in any serious health problems or diseases. Also, indicate if any of your family has ever had similar pain problems as you.
  • Social History

    Please tell us a little about yourself to help us get to know you better.
  • How many children have you had?   *   children

  • Who do you live with at home?*   

  • How far did you get in your education?*   level

  • Work History

    Tell us a little bit about your occupation status:
  • Habits

    Please check all that apply.
  • Quit smoking for   *   Years   *   Packs per day

  • Social consumption of alcohol*   alcoholic beverages/day 

  • *   caffeinated beverages/day

  • Drugs

  •  
  • Review Of Systems

  • Are you experiencing any of the following symptoms with regularity that is different than what listed before? If so, please check.

  • To the best of my knowledge, the information I recorded in this patient questionnaire is accurate and complete.

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  • Please Carefully Review the HIPAA Notice of Privacy Practices for Personal Health Information

  • This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

    Dear Patient:

    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 to provide this Notice to you by the Health Insurance Portability and Accountability Act ("HIPAA"). For additional information regarding our HIPAA Medical Information Privacy Policy or our general privacy policies, please write to us directly at Pain Management Attn: Privacy Officer, 339 Consort Drive, Ballwin, MO 63011-4439.

    We are required by law to:

    • Maintain the privacy of your Personal Health Information
    • Provide you this notice of our legal duties and privacy practices with respect to your Personal Health Information
    • Follow the terms of this notice.

    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.

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  • Patient Record Disclosure

  • 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.

  • Clear
  • Patient Record Disclosure

  • To whom may we talk to about your medical and billing information?

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  • Acknowledgement of Receipt of Pain Management Services Notice of Privacy Practices

  • By signing this document, I acknowledge that I have received a copy of Pain Management Services Notice of Privacy Practices.

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  • Please bring the following items with you:

    • INSURANCE CARD AND PHOTO ID
    • SPECIALIST COPAY/REFERRAL IF REQUIRED BY INSURANCE
    • ANY IMAGING FILMS/CDS REGARDING YOUR PAIN
    • PHARMACY PHONE NUMBER
    • LIST OF MEDICATIONS (STRENGTH, DIRECTIONS, QTY, AND DR. PRESCRIBING)
    • ADVANCE DIRECTIVE IF YOU HAVE ONE (LIVING WILL, ETC)

    WITHOUT THIS INFORMATION YOUR APPT. WILL NEED TO BE RESCHEDULED.

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