Northeast Pain Associates LLC
186 Princeton Hightstown Rd, Building 3B Suite 104West Windsor NJ 08550
Name
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First Name
Last Name
Date of Birth:
*
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Month
-
Day
Year
Date
SSN#:
Sex:
*
M
F
Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Ph:
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Format: (000) 000-0000.
Cell Ph:
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Format: (000) 000-0000.
Email:
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example@example.com
Referred By:
Ph:
Format: (000) 000-0000.
Family Doctor:
Ph:
Format: (000) 000-0000.
Date of Accident (if applicable):
-
Month
-
Day
Year
Date
Type of Accident:
Car
Work
Other
Primary Insurance
Primary Insurance:
Auto
Health
WC
Other
Claim or ID#:
Group#:
Ph# of Primary Insurance company:
Adjuster's Name:
Ph:
Format: (000) 000-0000.
Ex:
Secondary Insurance:
ID:
Ph# of Secondary Insurance:
Auto
Health
WC
Other
Attorney's Name:
Ph:
Format: (000) 000-0000.
Ex:
Employer Name:
Emergency Contact:
Ph:
Format: (000) 000-0000.
Are we authorized to release your medical information to the listed emergency contact?
Yes
No
Reason for Your Visit:
CONSENT TO TREAT
The patient has the right to informed participation to any decisions involving his/her health care. This shall be based on clear and concise explanation of his/her condition and of all proposed treatment plan and procedures. All possible risks and/or side effects, as well as the probability of success with such treatment and or procedures, shall be disclosed to the patient. Where medically significant, alternatives for care or treatment exists, the patient shall be so informed. After reading the above,
I
hereby consent to receive treatment at Northeast Pain Associates LLC
commencing on
I have read this information and understand its content in its entirely.
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Northeast Pain Associates LLC
NAME:
*
First Name
Last Name
DATE:
*
-
Month
-
Day
Year
Date
HISTORY OF ILLNESS / INJURY / PAIN
LOCATION
Chief complaint and its location:
How often do you experience this pain?
Constant
Frequent
Intermittent
TIMING & DURATION
What caused the onset?
Date of onset?
-
Month
-
Day
Year
Date
(Please list your most recent incident (minor or major) that prompted this visit.)
SEVERITY
On a scale of 0 to 10 with 0 representing no pain and 10 being the most severe pain imaginable, use the key below to rate the severity of your pain.
Severity of your pain
0 = None
1 = Minimal
2 = Minimal/Slight
3 = Slight
4 = Slight to Moderate
5 = Moderate
6= Moderate to Severe
7= Severe
Frequency
Frequency
None
Infrequent
Occasional
Occasional-Intermittent
Intermittent
Intermittent-Frequent
Frequent
Frequent-Constant
Constant
Sitting here today, right now, what is the intensity of your pain on a scale of 0 to 10?
1
2
3
4
6
7
8
0
1
2
3
4
5
6
7
8
10
What is the least intense the symptom has been on a scale of 0 to 10?
1
2
3
4
5
6
7
8
ASSOCIATED SIGNS & SYMPTOMS
If this pain radiates or travels, please identify where to:
Please check those that apply
Inflexibility
Stiffness
QUALITY/PAIN
How would you best describe the sensation of the pain/symptom:
Sharp
Dull
Stabbing
Aching
Radiating
Burning
Throbbing
Numbness/Tingling
MODIFYING FACTORS
What aggravates the pain/symptom?
None
Sleeping
Standing
Sitting
Lifting
Time on the computer
Talking on the phone
Walking
Running
Sneezing/Coughing
Bending
Working
Driving
Changing Positions
Exercise
Looking Up/Down
Looking Sideways
Getting In/Out of Bed
Pushing
Pulling
Repetitive Movement
Stress
Climbing Stairs
Stooping
Other:
What relieves this pain/symptom?
Sleeping
Standing
Ice
Heat
Stretching
Sitting
Rest
Looking Up/Down
Shower
NSAIDs like Advil/Ibuprofen
Lifting
Exercise
Other:
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NAME:
*
DATE:
*
-
Month
-
Day
Year
Date
Over the past weeks/months this complaint is:
Improving
Getting worse
About the same
Have you seen anyone in this condition?
YES
NO
WHOM?
How did you hear about us?
KEY VALUE QUESTIONS
What is your pain keeping you from doing that is most important in your life?
What do you enjoy doing most in your life?
NOTES / COMMENTS:
Please place a checkmark by the condition that applies to you: P = Present N = Not Present PP = If it has ever been present in the past:
Rows
PNPP
Column 4
PNPP
Column 8
P
PP
Column 12
PNPP
Column 16
1
2
3
4
5
6
7
Do you have a pacemaker?
YES
NO
Are you Pregnant?
YES
NO
Do you think you may be pregnant?
YES
NO
Rows
List any other key slips, falls or accidents you've had from childhood to present:
Date:
1)
2)
3)
1)
2)
3)
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NAME:
*
DATE:
*
-
Month
-
Day
Year
Date
NEUROLOGICAL MASCULAR QUESTIONNAIRE
1. Do you suffer from neck pain with pain in your shoulders, arms, or hands?
NO
YES
Comment:
1. Do you have weakness, numbness tingling or burning in your shoulders, arms or hands?
NO
YES
Comment:
2. Do your arms or hands fall asleep regularly?
No
Yes
Comment:
3. Do you have reduced feeling (sensation) or swelling in your arms or hands?
No
Yes
Comment:
4. Do you suffer from also so hand grip strength?
No
Yes
Comment:
5. Do you suffer from back pain with pain in your buttocks, legs or feet?
No
Yes
Comment:
6. Do you have weakness, numbness or burning in your buttocks, legs, or feet?
No
Yes
Comment:
7. Do your legs or feet fall asleep regularly?
No
Yes
Comment:
8. Do you have reduced feeling (sensation) or swelling in your legs or feet?
No
Yes
Comment:
9. Do you suffer from cold hands or feet?
No
Yes
Comment:
10. Have you tried any medications such as anti-inflammatory? If yes, what kind of medication?
No
Yes
Comment:
11. Have you tried any Physical Therapy before? If yes, when? For how long? What kind?
No
Yes
Comment:
12. Have you tried any Chiropractic treatments before? If yes, when? For how long? What kind?
No
Yes
Comment:
13. Have you had an MRI? If yes, when? Who ordered it? What was it ordered for?
No
Yes
Comment:
14. Have you had X-rays? If yes, when? Who ordered it? What was it ordered for?
No
Yes
Comment:
15. Have you used any splint or braces or other prescribed treatments by an M.D.? If yes, when?
No
Yes
What kind? Who ordered it?
Comment:
16. Have you used any splinter braces or other prescribed treatments by an M.D.? If yes, when?
No
Yes
What kind? Who ordered it?
Comment:
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AUTHORIZATIONS
TO RELEASE/RECEIVE INFORMATION
By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to Northeast Pain Associates LLC. I give my consent to Align Health and Wellness to disclose health information to my insurance carrier for the purpose of billing, to my primary physician, or any other healthcare professionals involved in my care. I agree to the release of my health information from other healthcare professionals as it relates to my treatment, as permitted/required by law. I understand that the confidentiality of my health information is protected under state and federal law, and that this release gives consent to Align Health and Wellness only, and not to any other party to whom such information is released.
Print Name:
*
Signature:
*
Date:
*
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Month
-
Day
Year
Date
PATIENT PAYMENT POLICY
The fee schedule of Northeast Pain Associates LLC is based on usual and customary fees for the type of services provided. Generally, your insurance policy will cover a portion, if not, the entire amount for the services provided. There is, however, no guarantee of partial or payment in full of the insurance company. The balance amount that your insurance carrier does not cover will be your responsibility. You are also responsible for any deductible and co-pay. In the event an insurance payment for Premier Med Group is sent to your address, you are required to present it to Align Health and Wellness, along with the explanation of benefits and/or any other information you received with the payment. If you should, inadvertently, deposit an insurance payment sent to you, you will be responsible for making the payment, for the amount paid by and owed to Align Health and Wellness. You are directly responsible for payment of medical supplies. Statements from Align Health and Wellness will be sent to you if you have an outstanding balance. Payment for your portion of services is requested to be paid within fifteen (15) days of receipt of the statement.
Print Name:
*
Signature:
*
Date:
*
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Month
-
Day
Year
Date
HIPAA DECLARATION
The Practice:
a) Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy
b) Notice detailing the Practice's legal duties and privacy practices with respect to your PH
c) Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions
on the use or release of your PHI than that which provided for under federal law is required to abide by the terms of
the Privacy Notice
d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice
provisions effective for all your PHI that it maintains.
e) Will distribute any revised Privacy Notice to you prior to implementation.
f) Will not retaliate against you for filing a complaint
Patient Communications:
Health Insurance Privacy Act 1996 requires we inform you of the following government stipulations for us to contact you with educational and promotional items in the future via email, U.S. mail, telephone, and/or prerecorded messages. We WILL NOT ever share, sell, or "SPAM" your personal contact information.
PATIENT ACKNOWLEDGEMENT
I acknowledge receipt of this notice, and my understanding and my agreement to its terms.
Print Name:
*
Signature:
*
Date:
*
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Month
-
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Year
Date
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