nevada pain & spine specialists - · pdf filepatient health history and pain...
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Nevada Pain & Spine Specialists
605 Sierra Rose Drive, Suite 1-4 Reno, NV 89511
Phone: 775-689-5410 Fax: 775-689-5432
Welcome to Nevada Pain & Spine Specialists
Thank you for choosing us to assist you in the management of your unique pain problems. We appreciate your trust in us and look forward to the opportunity to work with you and your referring provider.
To provide the best possible care for you it is essential that we have your current medical information. We have enclosed a Patient Health History and Pain Questionnaire to complete prior to your visit. If you prefer you can go to our website www.nevadapainandspinespecialists and create an account and complete it online. We request that you take the time to be thorough and complete since all of the information is important to the management of your care. Unfortunately, if the Patient Health History and Pain Questionnaire is not completed, we will not be able to see you at your scheduled appointment.
If you need assistance or have questions regarding the completion of the forms please call 775-398-1541 for Annie (Dr. Berman) or 775-398-1542 for Tina (Dr. Pitman) or 775-398-1543 Lonna (Dr. Wesely) prior to your appointment and they will be happy to assist you.
Please keep in mind this appointment is for an initial CONSULTATION/EVALUATION ONLY. PRESCRIPTION MEDICATIONS MAY NOT be prescribed at this appointment. It is extremely important that you continue medication management with your PCP/Referring physician. Once a NPSS physician has determined a
treatment plan and IF this treatment plan includes medication management, your PCP/Referring physician
will be notified.
All current medication bottles
Please bring the following to your appointment:
Completed Registration Form) If relevant, X-Ray and/or MRI films Completed Patient Health History and
Pain Questionnaire
Drivers License or Photo Identification. Current Health Insurance Card(s) Current Prescription Card Co-payment (if required by your
insurance)
If for any reason, you have to cancel and/or reschedule your appointment; please notify us at least 24 hours in advance. Again, you can cancel and/or request to reschedule utilizing our website. If we do not receive notification 24 hours prior to your appointment there is a $50.00 “No Show” charge and we will notify your referring provider of the “No Show” and will not reschedule your consultation without a new referral.
We want to thank you for taking the time to prepare for you appointment. If you have any questions, or need assistance of any kind, please call Annie at 775-398-1541 or Tina at 775-398-1542 or Lonna at 775-398-1543
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We are located at 605 SIERRA ROSE DR. RENO, NV, 89511
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Demographics:
Please fill in the following:
Name: Today’s Date Social Security Number:
Date of Birth: Age: Sex:
Address City State:
Home Phone: Work Phone: Cell Phone:
Employment Status: Employer Name:
Occupation/ Title:
Address: City: State: Zip:
Emergency Contact: Relationship to Patient: Home Phone: Cell Phone:
Authorizations:
Leave a message on your home answering machine/voicemail? Yes No
Leave a message with a family member/member of your household Yes No
Leave a message at your place of employment? Yes No
Discuss your medical condition with a family member/member of your household/friend/other? Yes No If yes, please list: ___________________________________________________________________________________________ Release any of your medical information (office notes, lab reports, etc. &.) to a family member/member of your household/friend/other? Yes No If yes, please list: ___________________________________________________________________________________________ Discuss your medical billing or insurance information with a family member/member of your household/friend/other? Yes No If yes, please list:
_________________________________________________________________________________________
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Draw your pain on the human diagram below. Use arrows to show where your pain may shoot or spread. Circle the words that best describe your pain and use the symbols to locate your pain: X - Stabbing, sharp, cutting - Pressure, squeezing, throbbing
- Dull, aching b - Burning, hot
- Tingling, pins and needles, numbness
- Direction of shooting or spread
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History of Present Illness:
What pain problem are you seeing us for? _________________________________________________________ Who referred you to us? _____________________________________________________ Please list current treating physicians/ providers: Include name and city ___________________________________________________________________________________________
___________________________________________________________________________________________
When did your pain start? ______________________________________
What do you think caused your pain?
_____________________________________________________________________________
Please select the responses that apply to your pain:
started suddenly started gradually has stayed the same
has worsened rapidly has worsened gradually has slowly improved
has happened before has never happened before
At best, how severe is your pain on a scale of 0-10? (0=no pain, 10=worst pain possible) _____________
At worst, how severe is your pain on a scale of 0-10? (0=no pain, 10=worst pain possible) _____________
On average, how severe is your pain on a scale of 0-10? (0=no pain, 10=worst pain possible) _____________
What would be an acceptable level of pain? (from 1 to 10: 0 = no pain, 10 = worst pain possible) _____________
How often do you experience your pain problem?
Steady or constant Brief or momentary Comes and goes Never changes
Pain problem occurs:
Daily Weekly Monthly Less Often Pain problem is worse during:
Mornings Afternoons Evenings Bedtime N/A Pain is the same all the time
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Describe your pain:
dull sharp aching pounding throbbing cramping burning tingling electrical shooting numbing pins/needles
What worsens your pain?
sitting bending lifting
twisting coughing/sneezing standing
walking reaching exercise
certain positions stress damp/cold
heat light touch certain foods
other none If other, please explain _______________________________________________________________________ What helps your pain?
sitting heat quiet ER Visits
standing stretching relaxation injections
reclining massage exercise medications
other none
If other, please explain _______________________________________________________________________ Symptoms associated with your pain:
numbness weakness swelling
stiffness cramps weight loss
fever chills sweats
fatigue skin changes hair changes
nail changes rashes skin coolness
bowel problems bladder problems paralysis
balance problems depression anxiety
insomnia suicidal none
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Your pain interferes with:
work sleep personal care
sexual relations driving yard work
light work heavy work using the bathroom
walking short distances walking long distances shopping
other none
If other, please explain _______________________________________________________________________
Past non-surgical treatments you have had (how helpful?):
N/A No Help
Some Help
Much Help
Worse
Epidural blocks
Trigger point injections
Physical Therapy
Chiropractic Acupuncture Biofeedback
Massage
TENS/ Electrical Stimulation Psychological counseling Hypnosis
Nutritional/ Herbal therapy
Pain/ Rehab program
Other? If other, please explain _______________________________________________________________________
List all surgeries you have had to treat your pain: Please include date, surgical procedure, and indicate if it was No Help, Some Help, Much Help, Worse.
Surgeries/Pain Treatment:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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What studies have been used to evaluate your pain?
MRI CT
X-Rays EMG
Discogram Ultrasound
Disability/ Impairment Rating Psychological Testing
Other None If other, please specify _______________________________________________________________________
Your current pain treatment is:
Poor Fair Adequate Good No Treatment Review of Systems:
General: Fatigue Weight Gain Weight Loss
Skin: Excessive Sweating Rash Pigmentation Change In Hair Growth Or Loss
Nail Changes Skin Color Changes Bruising Hair Growth Hair Loss
HEENT: Visual Loss Hearing Loss Glaucoma Nose Bleed Hoarseness
Respiratory: Bloody Sputum Cough Wheezing Shortness Of Breath
Cardiovascular: Chest Pain Fainting Swelling Of Extremities Irregular Heart Beat
Gastrointestinal: Abdominal Pain Constipation Nausea Vomiting Incontinence Of Stool
Genitourinary: Urinary Infections Kidney Stones Blood In Urine Incontinence
Musculoskeletal: Joint Pain Muscle Weakness Fractures Muscle Pain Muscle Cramps
Joint Swelling
Neurological: Trouble Walking Balance Problems Headaches
Cancer: please specify which type, where, and indicate if you received surgery, chemotherapy, radiation
therapy, or hormone therapy. :
___________________________________________________________________________________________
Medical History:
Current PAIN medications (include strength/dosage and how many per day): Type "None" if not taking any.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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Please list any previous pain medications and indicate why they were discontinued: ___________________________________________________________________________________________
___________________________________________________________________________________________
How long have you been taking prescription pain medications? _______________________________________
Please list all other medications you are currently taking (include strength/dosage and how many per day):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Do you have any medication allergies? If yes, please list: ___________________________________________________________________________________________
List other SURGERIES and HOSPITALIZATIONS, please include approximate dates:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Please list any other medical conditions:
Heart Attack Heart Failure
Hypertension High Cholesterol
COPD Diabetes Type I
Diabetes Type II Asthma
Stroke Peripheral Vascular Disease
Migraine Headaches High Thyroid
Low Thyroid Chronic Bronchitis
Tuberculosis Seizure Disorder
Liver Disease Hepatitis
Fibromyalgia Other
None If other, please explain _______________________________________________________________________
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Tobacco/Alcohol/ Drugs:
Do you smoke? If yes, how much: ________________________________________________________________
Do you drink alcohol? If yes, how much: ___________________________________________________________
Do you use any illicit substances? If yes, which substances? How much?
___________________________________________________________________________________________
Psychiatric History:
Have you previously experienced any mental/psychiatric condition such as?
Depression Anxiety Bipolar Disorder
Alcoholism Post Traumatic Stress Disorder Schizophrenia
Childhood Trauma/ Abuse Suicidal Ideation/ Attempt None
If yes to any of these conditions, please explain:
___________________________________________________________________________________________
Have you ever struggled with or received treatment for substance addiction/abuse
___________________________________________________________________________________________
Have you ever used alcohol or illicit substances to control your pain?
__________________________________________________________________________________________
Are you under the care of a mental health provider? If yes please list the name and phone number of your provider:
___________________________________________________________________________________________
Family History
Please list any medical problems that run in your family: Write “none” if you do not have any
___________________________________________________________________________________________
Social History
Birthplace: ____________________________________
Marital Status: _____________________________________
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Children? If so, how many/ ages? _______________________________________________
Who do you live with? ______________________________________
Occupational History
Work Status: _________________________________________
Please describe your current job: (if you are not working, write n/a)
___________________________________________________________________________________________
What is your level of education?___________________________
Work Related Injury Information: ONLY COMPLETE THIS SECTION IF THIS IS A WORK-RELATED/WORK COMP INJURY
What body part is/are covered? _________________________________________________________________
Who was your employer? ______________________________________________________________________
How long had you been working there? __________________________________________________________
What was your job? __________________________________________________________________________
How long has it been since you last worked? ______________________________________________________
What type of work had you previously performed? _________________________________________________
BAPSI Questionnaire
The following survey is concerned with how your pain has changed your life. You will be presented with a series of statements. For each statement circle the one answer that best describes how much you agree or agree with the statement. For example, if you strongly agree with an item, answer 5, 6, or 7. If you strongly disagree with an item, answer 0, 1, or 2. If you moderately agree or feel neutral about an item, answer 3 or 4.
1. I'm not as physically strong as I used to be before developing pain:
1 2 3 4 5 6 7
2. I avoid situations that might make my pain worse:
1 2 3 4 5 6 7
3. I don’t have as much energy as I used to before developing pain:
1 2 3 4 5 6 7
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4. I do not sleep as well as I used to before developing pain:
1 2 3 4 5 6 7
5. I take prescription pain medication daily:
1 2 3 4 5 6 7
6. I’m not as physically active as I used to be before developing pain:
1 2 3 4 5 6 7
7. I have felt stressed during the past week:
1 2 3 4 5 6 7
8. I have gone to the emergency room in the past 6 weeks because of my pain:
1 2 3 4 5 6 7
9. I have been off work more than 6 weeks because of my pain:
1 2 3 4 5 6 7
10. I have lost interest in many activities I used to enjoy:
1 2 3 4 5 6 7
11. I am having difficulty taking care of my Responsibilities because of my pain:
1 2 3 4 5 6 7
12. I find it difficult motivating myself to do things:
1 2 3 4 5 6 7
13. I use alcohol to cope with my pain:
1 2 3 4 5 6 7
14. I have experience feelings of sadness and depression during the past week:
1 2 3 4 5 6 7
15. My sex life is not a satisfying as it used to be before developing pain:
1 2 3 4 5 6 7
16. My pain has caused problems in my marriage/relationship:
1 2 3 4 5 6 7
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17. I’ve visited a doctor, chiropractor, or physical therapist more than 10 times in the past month because of my pain:
1 2 3 4 5 6 7
18. Over the past week, I have felt useless and inadequate:
1 2 3 4 5 6 7
19. My pain problem is more than I can handle:
1 2 3 4 5 6 7
20. I worry about re-injuring myself:
1 2 3 4 5 6 7
21. I have felt irritable during the past week:
1 2 3 4 5 6 7
22. I am not able to work as well I used to before developing pain:
1 2 3 4 5 6 7
23. I cannot do my chores around the house as well as I used to before developing pain:
1 2 3 4 5 6 7
BAPSI Questionnaire Part 2 For the following questions, rate average how much your pain has limited your activity in the past week, including today: 0 = least, 10 = worst
1. Rate, on the average, any pain you might have had during the last week:
1 2 3 4 5 6 7 8 9 10
2. Rate, at its least, any pain you might have had during the last week:
1 2 3 4 5 6 7 8 9 10
3. Rate, at its worst, any pain you might have have had during the last week:
1 2 3 4 5 6 7 8 9 10
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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Acknowledgment of Notice of Privacy Practices
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and controls your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.
TREATMENT: Nevada Pain & Spine Specialists will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
PAYMENT: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
HEALTHCARE OPERATIONS: Nevada Pain & Spine Specialists may use or disclose, as-needed, your protected health information in order to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other alternatives or other health-related benefits that may be of interest to you.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, worker's compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your
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protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164-500.
OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke the authorization, at any time, in writing, except to the extent that Nevada Pain & Spine Specialists has taken an action in reliance on the use or disclosure indicated in the authorization.
YOUR RIGHTS
The following are statements of your rights with respect to your protected health information.
-You have the right to inspect and copy your protected health information (fees may apply):
**Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.
-You have the right to request a restriction of your protected health information:
**This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friend who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to your requested restriction.
-You have the right to request to receive confidential communications:
**You have the right to request confidential communication from us by alternative means or at any alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
-You have the right to request an amendment to your protected health information.
**If we deny your request for amendment, you have the right to file a statement of disagreement with us and may prepare a rebuttal to your statement and we will provide you with a copy of any such rebuttal.
-You have the right to receive an accounting of certain disclosures.
**You have the right to receive an accounting of all disclosures except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of his request.
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We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.
COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.
Nevada Pain & Spine Specialists is required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please speak with our HIPAA Compliance Officer in person or by phone at our main number.
Please sign the accompanying Acknowledgement form. Please note by signing the Acknowledgement form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.
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ACKNOWLEDGEMENT OF PRIVACY PRACTICES I have read the Notice of Privacy Practices and understand my rights contained in the notice.
Patient Signature: ______________________________________________________________
Date: ______________________________________________________________
Witness: ______________________________________________________________________
Date: ______________________________________________________________
THANK YOU FOR COMPLETING OUR PAPERWORK, WE LOOK FORWARD TO MEETING YOU