New Patient Physical Medicine/Neuropathy Form

Your Integrative Health Partners

19701 W 65th Terrace, Shawnee, KS 66218
Please fill out anything that has a *. If that question does not pertain to you, fill it in with an NA or Zeros. If you do not fill the form in completely it will not allow you to submit it. If you need to walk away from the form, you will need to set up an account and save the form. If you do not do this your form will be BLANK the next time you come back to it.

Thank you
Legal Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:*
Age:*
Sex:*
Cell Phone:*
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Email:*
example@example.com
Social Security Number:(for insurance verification)*
Height:*
Weight:*
Race:*
Status:*
Is patient a Minor?*
If patient is a minor: Parent/Guardian Name:
Parent/Guardian Phone Number:
Patients Occupation:*
Patients Employer:*
Work Phone Number:*
Please enter a valid phone number.
In Case of Emergency:*

First NameLast Name
Relationship:*
Phone Number:*
Please enter a valid phone number.
How Did You Hear About Us?*
Referral:*
Medical Information:

Please fill out to the best of your ability.
Clinic Name:*
Primary Care Physician's Name:*
Phone Number:*
Please enter a valid phone number.
Clinic Fax Number:*
Please enter a valid phone number.
I allow my health progression to be shared with my primary care physician:*
What brings you in to the office today (major complaint)?*
Who have you seen in the past for this problem? What previous treatment have you done for this condition? Please list below:*
What were the results of this/these previous treatments?*
How many years have you had the complaint/pain?*
What do you feel the gap has ben between the past/current treatment and the goals you are trying to achieve?*
How does this problem interfere with your daily life?*
Have you considered surgery?*
Have you had any Nerve Testing/EMG?*
If 'YES' when?
What is your main concern about your complaint(s)?*
On a scale from 1 to 10 (10 high), what is your interest in getting help for your complaint(s)?*
List all recent X-ray's, CT Scans, and/or MRI's, when and state the results.*
Medical History

to the best of your knowledge
Injuries/Accidents- Please provide the date and the reason*
Surgeries- Please provide the date and the reason*
Hospitalizations- Please provide the date and the reason*
Review of Systems

Check appropriate box(es)

Co-Conditions:*

	Past	Ongoing	Never
Anesthesia Problems
Aneurysm
Blood Clots
Blood Pressure; High/Low
Blood Thinners
Chest Pain
Chemical Exposure; Pesticides/Agent Orange
Constipation
COPD
Cough; Recurrent/Chronic
Diabetes' Type 1/Type 2
Diarrhea
Dizziness
Emphysema
Epilepsy
Fibromyalgia
GERD
Gout
Headaches/Migraine
Heart Disease/Palpitations
Hepatitis
Hernia
High Cholesterol
HIV
Implanted Cord/Bladder Stimulator
Kidney Disease
Lung Disease
Lupus
Morton's Neuroma
MRSA
Neuropathy
PACEMAKER/DEFIBRILLATOR
Paralysis
Plantar Fasciitis
Polio
Poor Circulation
Poor Wound Healing
Shingles
Skin Pigment Changes
Sleep Apnea
Spider Veins
Stroke/TIA
Swelling Feet/Ankles
Tuberculosis
Ulcers/Amputations
Vascular Issues/Disease
Varicose Veins
Vitamin Deficiency; B12 or D3

Musculoskeletal:*

	Past	Ongoing	Never
Arthritis; Hands/Feet
Balance Issues/Falls
Degenerative Disc
Disc Bulge
Disc Herniation
Fusion
Joint Replacement
Foot; Pain/Numbness
Hand; Pain/Numbness
Leg; Pain/Numbness
Knee Pain
Lower Back Pain
Neck Pain
Pinched Nerve
Sciatica; Right/Left/Both
Spinal Fractures
Spinal Stenosis
Spinal Arthritis
Upper Back Pain

Please choose from the list below what you have tried to relieve your symptoms:*

Advil/IbuprofenAleve/NaproxenAmitriptylineCBD/Hemp ProductsChiropractic CareCreamsCymbaltaGabapentinInjectionsLyricaMassage TherapyMotrinNeurontinOpiodsPhysical TherapyTylenol/ AcetaminophenNone of the above
Are you currently taking a BLOOD THINNER? (Coumadin, Lovenox, Heparin, etc)*
Are you currently taking a STATIN? (Atorvastatin, Lipitor, Crestor, Simvastatin, etc.)*
Have you been previously diagnosed with Cancer?*
Do you currently have Cancer?*
If 'YES' please tell the type of cancer and when you were diagnosed:
If you have previously had cancer or currently have cancer please fill out the following questions. If you answered 'no' to both questions you can skip the next 3 questions.
Did you have Radiation?
Did you go through Chemotherapy?
Are you taking Cancer specific medication?
Name of Cancer specific medication:
Family History
Biological Mother:*
Cause of Death:
Relevant Health History:
Biological Father:*
Cause of Death:
Relevant Health History:
Medication Information

please list: name, dose, start date, and reason for use
Current Medication (RX):*
Nutritional Supplements (non RX):*
Have your medications or supplements ever caused unusual side effects or problems? If 'YES' describe them below. *
Do you have any surgical devices or pins/screws in your body?*
If 'YES' please list below where and when.
List all allergies. intolerances, or sensitivities below. (Drugs/Medications, Food, Environmental/Chemical)*
Neuropathy Symptoms ONLY

skip if you do not have Neuropathy symptoms
How would you describe your overall physical appearance of your feet and legs? (Choose all that apply)*

Blisters/SoresDiscoloration of Skin(red/pale)Petechiae(red spots)Cyanosis(blue/purple skin)Discoloration of ToenailsFungus(on skin/nails)Dry or Flaky SkinLoss of ToenailsNo Hair GrowthNone of the above
Have your symptoms changed over time?*

WorsenedStayed the sameImprovedNone of the above
How frequent is your discomfort?*

Constant 75-100%Frequent 51-75%Occasional 25-50%Intermittent 0/25%None of the above
Is there a certain time of day the symptoms seem to be worse?*

MorningMid-DayEveningOvernightNone of the above
On an average day this past week: How severe would you rate your overall discomfort level? (no discomfort-0 worst discomfort possible-10)*
If you still experienced some levels of discomfort after completion of this program, what would be an acceptable level? (no discomfort-0 worst discomfort-10)*
On a scale of 1-10, how committed/serious are you about getting your health concern corrected? (not serious-0 totally committed-10)*
Current Condition Symptoms:

Please choose all that apply
Neck:*

AchingColdDull PainHypersensitivePins & NeedlesSharp PainStiffnessThrobbingWeaknessBurningCrampsHotNumbnessStabbingSpasmsSwellingTinglingNone of the above
Upper Back:*

AchingColdDull PainHypersensitivePins & NeedlesSharp PainStiffnessThrobbingWeaknessBurningCrampsHotNumbnessStabbingSpasmsSwellingTinglingNone of the above
Mid Back:*

AchingColdDull PainHypersensitivePins & NeedlesSharpStiffnessThrobbingWeaknessBurningCrampsHotNumbnessStabbingSpasmsSwellingTinglingNone of the above
Lower Back:*

AchingColdDull PainHypersensitivePins & NeedlesSharp PainThrobbingWeaknessBurningCrampsHotNumbnessStabbingSpasmsSwellingTinglingNone of the above
Lower Extremities:*

AchingColdDull PainHypersensitivePins & NeedlesSharp PainThrobbingWeaknessBurningCrampsHotNumbnessStabbingSpasmsSwellingTinglingNone of the above
Daily Activities

Effects of Current Condition on Daily Performance

Please mark for each CURRENT Condition*

	No Effect	Slightly Limited	Limited	Mostly Limited	Unable to Perform
Bending
Cleaning
Climbing
Computer Work
Concentrating
Cooking
Dancing
Dressing
Driving
Jumping
Lifting
Playing Sports
Pushing
Running
Sexual Activity
Sitting
Sit to Stand
Sleeping
Stairs
Standing
Walking
Working
Vacuuming
Yardwork

Lifestyle
Check your exercise Level:*
Are you a CURRENT tobacco user?*
Type and Amount per Day
Are you a PREVIOUS tobacco user?*
Type, amount per day, date of quitting
Are you exposed to second hand smoke regularly?*
Are you a CURRENT alcohol drinker?*
How many drinks per week?
Are you a PREVIOUS alcohol drinker?*
How many drinks per week?
Do you currently or have you previously used recreational drugs?*
If 'YES', what types and method(IV, inhaled, smoked, etc)?
Work Status:*

Full-TimePart-TimeHomemakerStudentUnemployed
How many hours a week do you work?*

<56-89-10>10
Are you mostly:*

SittingWalkingStandingHeavy Lifting
Accident Information
Is your condition due to an accident?*
If 'YES' please provide the date if the accident below.
Type of Accident:

AutoWorkHomeOther
To whom have you made a report of your accident?

Auto InsuranceEmployerWork CompOther
Attorney Name: (if applicable)
Attorney Phone Number: (if applicable)
Please enter a valid phone number.
Fatigue Severity Scale
Please choose a number for each of the following nine statements to indicate how much you agree with each statement.

1 represents strongly disagree

4 represents neither disagree nor agree

7 represents strongly agree

Please answer the questions with reference to how you have felt on average over the last week.

Fatigue Severity Scale*

	1	2	3	4	5	6	7
My motivation is lower when I am fatigued
Exercise brings on my fatigue
I am easily fatigued
Fatigue interferes with my physical functioning
Fatigue causes frequent problems for me
My fatigue prevents sustained physical functioning
Fatigue interferes with carrying out certain duties and responsibilities
Fatigue is among my three most disabling symptoms
Fatigue interferes with my work, family, or social life

Allergy
Do you suffer from seasonal allergies?*
If 'YES' which season(s)

SpringSummerFallWinterAll Year
If 'YES' which of the following symptoms do you typically have? Choose all that apply.

SneezingItchy and/or Watery EyesScratchy ThroatPostnasal DripJoint PainItchy Dry SkinCongestionChronic CoughRestlessnessHivesRunny Nose
Other: List below
How long have you had these symptoms? List below.
When do you typically experience them the most?

MorningAfternoonNightAll day
Do you frequently get sinus infections, colds, the flu, or a runny nose?
Have you been diagnosed with Asthma?*
If 'YES' is it controlled?
Do you take any antihistamine medication to control these symptoms?
If 'YES' please list them below and the date last taken.
Have you been allergy tested in the last 12 months?
If 'YES' are you on immunotherapy?
Are you planning to relocate in the next 12 months?
Have you ever had a life-threatening allergic reaction that needed emergency medical attention?
Do you have any known food allergies?
If 'YES' please list below.
Assignment and Release:

I understand and agree that (regardless of whatever health or medical benefits I have), I am ultimately responsible to pay LIFEWORKS INTEGRATIVE HEALTH/INTEGRATIVE HEALTH PARTNERS, LLC, the balance due on my account for any professional services rendered and for any supplies, tests or medications provided.

I hereby authorize payment of any health insurance or medical plan benefits directly to LIFEWORKS INTEGRATIVE HEALTH/INTEGRATIVE HEALTH PARTNERS, LLC, for medical services rendered and for any supplies, tests or medications provided.

I hereby authorize the release of any: health status, conditions, symptoms or treatment information contained in your records that is needed to file and
process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. Patient irrevocably assigns all of his/her rights and benefits and right to pursue enforcement of such benefits, under any policy of insurance, indemnity, health plan (including self-funded), or any collateral source to LIFEWORKS INTEGRATIVE HEALTH/INTEGRATIVE HEALTH PARTNERS, LLC, including the right to submit claims for reimbursement and payment for services rendered, and authorizes direct payment to the provider of any benefits otherwise payable to or on behalf of the Patient. Patient assigns permission to Provider his/her right to pursue payment, appeals, claims, causes of action, penalties, administrative, and/or legal remedies including the right to bring claims under enforcement provisions of ERISA, against any responsible source of payment including but not limited to any insurer, health plan (including self-funded), health carrier, hospital or medical service corporation, ERISA plan or administrator, for any and all benefits due me under my benefit plan. Provider is expressly authorized to bring any and all claims to enforce my rights under ERISA, including right to payment, breach of fiduciary duty, breach of contract, civil penalties, or any other claim or remedy. Provider is authorized to make such claims, institute legal or alternative dispute resolution proceedings, enter into settlements or compromises and any other acts necessary to pursue my rights and benefits. This assignment extends to any affiliates, agents, and/or assignees of Provider. Patient hereby appoints Provider as his/her authorized representative and attorney-in-fact for such activities, and authorizes Provider to take such actions in the name of Provider and/or the Patient. If I receive payment directly from any source for the services I receive from Provider, I agree it is my duty and responsibility to immediately pay any such amounts to Provider.
Signature of Patient, Parent, Guardian or Personal Representative:*

First NameLast Name
Relationship to Patient:*
Signature:*

Clear
Date Completed and Signed:*

MonthDayYear
Date
We ask that you realize that we do NOT work for an insurance company. Rather we work 100% for our patients. We feel that insurance can be a great benefit for many patients and want you to know we will do everything in our power to ensure you get every benefit allotted in your insurance contract.
However; the treatment we recommend and the fees we charge WILL ALWAYS BE BASED ON YOUR INDIVIDUAL NEEDS, NOT YOUR INSURANCE COVERAGE.

Notice of Privacy Practices Acknowledgement
I understand that under the Health Insurance Portability and Accountability Act (HIPPA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have received or have been given the opportunity to receive a copy of your Notice of Privacy Practices. I also understand that this practice has the right to change its Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Pricavy Practices.
Signature*

Clear

Privacy and Billing Consent Form
This consent is required by the Health Insurance Portability Act of 1996 to inform you of your rights for privacy with respect to your health are information.

Consent Related to Privacy Notice:

I have had a chance to review the Practice Privacy Notice as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I understand I have the right to restrict how this infromation is disclosed, but this practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it is bound by that agreement.

Consent for Care:

I, with my signature, authorize LifeWorks Integrative Health and any employee working under the direction of the physician, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale of dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.

Consent for Release of Information and Assignment of Benefits:

I also authorize this practice to furnish information to the identified insurance carrier(s) for any and all payment activities. I consent to assign all payments for sevices directly to this practice. I further consent to the use for any practice operational needs as identified in the Practice Privacy Notice.

Financial Policy:

We appreciate you choosing us for your healthcare. We will adhere to the following financial policy in order to consistently deliver high quality care and services. The patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the health care services received.
- I understand that I am responsible for the co-payments, amounts applied to deductibles, and other amounts that may be deemed my responsibility by the payment sources, as required by my contract with my insurance plan and state regulations.
- I understand that if I have an insurance co-payment, I am expected to make payment when checking in for my appointment.
- I understand that my contract with my insurance entity may or may not cover some services. All insurance policies are not the same. They vary by employer group. LifeWorks Integrative Health is not responsible or able to know every policy available. It is my responsibility to verify applicable coverage prior to receiving the services. For example, not all health plans include screenings as a benefit. If I seek care outside or the contracted terms, I am aware that I may be responsible for all the charges that are incurred.
Signature*

Clear
Should be Empty:

Your Integrative Health Partners

Medical Information:

Medical History

Review of Systems

Family History

Medication Information

Neuropathy Symptoms ONLY

Current Condition Symptoms:

Daily Activities

Lifestyle

Accident Information

Fatigue Severity Scale

Allergy

Notice of Privacy Practices Acknowledgement

Privacy and Billing Consent Form