New Patient Packet

New Patient Packet
Patient Name:*

First NameMiddle NameLast Name
D.O.B:*

MonthDayYear
SSN #:*
Name of Doctor or Location*

Patient Contact Information
Email Address:*
Primary Phone #:*
Secondary Phone #:
Fax #:
Emergency Contact Name*
Emergency Contact #:*

Patient Home Address
Address:*

Address

CityState

Zip

Patient Information
Race:*
Ethnicity:*
Preferred Language:*
Smoking Status:*

Never SmokeCurrently SmokeQuit SmokingSocially Smoke

Primary Care Information
Primary Care Doctor's Name:*
Phone #:*
Address:*

Address

CityState

Zip

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.
Pharmacy Name:*
Pharmacy's Phone #:*
Address:*

Address

CityState

Zip

Insurance Information
Insurance Provider:*
Member ID:*
Group Number:*
Phone #:*

Medication List

This must be filled out entirely in order for your doctor to be able to prescribe you any medications.
What current medications are you taking?

Allergies
Have you ever experienced any allergic reactions from medication?

Please answer the following questions:
Have you been seen at another pain clinic?*

YesNo
When:*
By Whom:*
Were you referred to us by another doctor?*

YesNo
Referring Doctor:*
Phone Number:
Fax Number:
How did you hear about Pain Management Services?*

Past Surgical History
Have you had any surgeries in the past? Please list (even if they seem unrelated to your pain)

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.
Mother:
Father:
Brother:
Sister:
Grand Parents:

Social History

Please tell us a little about yourself to help us get to know you better.
Marital status:*

MarriedDivorcedWidowedSingle
Are you pregnant or do you plan to become pregnant?*

YesNo
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

Work History

Tell us a little bit about your occupation status:
Employment Status*
If currently employed, what is your type of employment / occupation:
If married, describe spouse's occupation:
Are you being treated under workman's compensation?*

YesNo
Are you currently receiving disability benefits?*

YesNo
Are you involved in legal action related to your pain problem or considering it in the future?*

YesNo
If yes, describe your current state of litigation:

Drugs
Do you use or have you ever used recreational drugs?*

YesNo
If yes, which drugs? *
Have you ever undergone drug or alcohol rehabilitation?*

YesNo
If yes, for which drugs?*
Have you ever misused or abused prescription drugs?*

YesNo
If yes, which drugs?*

Have you had any of the following tests performed within the last 24 months?

	Date	Facility	Results
Xray
CTscan
MRI
Myelogram

To the best of my knowledge, the information I recorded in this patient questionnaire is accurate and complete.
Approval Signature:*

Clear
Patient or Guardian

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.
Approval Signature:*

Clear
Patient or Guardian

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.
I wish to be contacted in the following manner by Pain Management Services (Check all that apply)

O.K. to leave a message with detailed information.O.K. to leave a message with call back number only.O.K. to mail to home addressO.K. to mail to work/office addressO.K. to fax the number included on this form
Approval Signature:*

Clear
Patient or Guardian

Patient Record Disclosure
To whom may we talk to about your medical and billing information?
Name of Spouse:
Phone Number:
Name of Parent:
Phone Number:
Name of Child:
Phone Number:
Other:
Phone Number:
Approval Signature:*

Clear
Patient or Guardian

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.
Name*

First NameMiddle NameLast Name
Approval Signature:*

Clear
Patient or Guardian

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.
Should be Empty:

New Patient Packet

Patient Contact Information

Patient Home Address

Patient Information

Primary Care Information

Pharmacy Information

Insurance Information

Medication List

Allergies

Please answer the following questions:

Please answer the following questions:

Please answer the following questions:

Please answer the following questions:

Please answer the following questions:

Please answer the following questions:

Past Medical History

Past Surgical History

Family History

Social History

Work History

Habits

Drugs

Review Of Systems

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

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

Patient Record Disclosure

Patient Record Disclosure

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

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.

Please bring the following items with you: