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Patient Name: _____________________________________Age ______

Male Female Right handed Left handed Ambidextrous

History of Problem for which you are being seen:

Reason for visit: _____________________________________________________________

By whom were you referred to our practice?_________________________________________

Expectations from treatment:___________________________________________________

Type of injury: Job Accident Sports Injury Other: _________________

Car accident: Driver Passenger Seat-belted: Yes No Airbag: Yes No

Date injury/symptoms started: _____________________________________________________

Do you have cancer? Yes No Cancer Type/Stage: __________________________________

How would you describe your mood in a word or two? ________________________________

On the diagram below, shade the areas where you feel pain. Put an “x” where it hurts the most;

check all terms that apply.

Aching

Burning

Stabbing

Shooting

Constant

Transient

Sharp

Dull

Mild

Moderate R L L R

Severe

Unbearable

Numbness

Tingling

Rate your pain by circling the one number that best describes your pain at its worst:

0 1 2 3 4 5 6 7 8 9 10

No Pain Pain worst imaginable

Rate your pain by circling the one number that best describes your pain at its least:

0 1 2 3 4 5 6 7 8 9 10

No Pain Pain worst imaginable

Rate your pain by circling the one number that best describes your pain on the average:

0 1 2 3 4 5 6 7 8 9 10

No Pain Pain worst imaginable

NEW PATIENT HEALTH HISTORY AND

PAIN QUESTIONNAIRE

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What makes pain worse: __________________________________________________________

What makes pain better: _________________________________________________________

Time of the day when pain is worse:___________________________________

Do you have the following?:

Weakness in your: arms right left legs right left

Numbness in your: arms right left legs right left

New or recurrent problems with bowel or bladder control? Yes no

Change in pain with cough/sneeze/bowel movements? Yes no

Medication History Indicate what you have used for your current pain condition:

If you have tried any of the listed medications, please indicate whether it helped with your pain or not by

checking the appropriate box. If you have not tried an agent, check “never tried”

Narcotics/Opiates: Did it help? Yes/No Never tried

Butrans Patch

Codeine (Tylenol #3)

Fentanyl Patch (Duragesic)

Hydrocodone (Vicodin, Norco)

Hydromorphone (Dilaudid,Exalgo)

Morphine (Kadian, MS Contin)

Methadone

Nucynta

Oxycodone (Oxycontin)

Oxymorphone (Opana)

Tramadol (Ultram)

Other/Comments:_________________________________________________________________

Antiinflammatories: Did it help? Yes/No Never tried

Aspirin

Celebrex (Celecoxib)

Diclofenac (Voltaren)

Etodolac (Lodine)

Ibuprofen (Motrin, Advil)

Indomethacin

Meloxicam (Mobic)

Naproxen (Aleve, Naprosyn)

Nabumetone (Relafen)

Tylenol

Other/Comments:_________________________________________________________________

Antineuropathics: Did it help? Yes/No Never tried

Amitriptyline

Duloxetine (Cymbalta)

Gabapentin (Neurontin)

Milnacipran (Savella)

Nortriptyline

Pregabalin (Lyrica)

Topiramate (Topamax)

Other/Comments:_________________________________________________________________

Muscle Relaxants: Did it help? Yes/No Never tried

Baclofen

Carisoprodol (Soma)

Chlorzoxazone (Lorzone)

Cyclobenzaprine (Flexeril)

Metaxalone (Skelaxin)

Methocarbamol (Robaxin)

Tizanidine (Zanaflex)

Other/Comments:_________________________________________________________________

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TREATMENT HISTORY: If you have tried any of the listed treatments, please indicate whether it helped with your pain or not by

checking the appropriate box. If you have not tried an agent, check “never tried”

Treatment: Did it help? Yes/No Never tried

Physical Therapy

Chiropractic

TENS Unit

Acupuncture

Trigger Point injections

Joint injections

Facet block/Medial Branch Block

Epidural Steroid Injection

Radiofrequency Ablation

Spinal Cord Stimulator

Psychiatric/Psychological care

Other/Comments:_________________________________________________________________

Name of prior Pain Physician(s): _____________________________________________

Are you currently taking Anticoagulants/Blood Thinners? Yes/No

If yes, what type?

Warfarin/Coumadin Aspirin Lovenox Other________________

Plavix (Clopidogrel) Eliquis Heparin

Pradaxa Arixta Herbals (Garlic, Ginko, Ginseng, Vitamin E)

Why are you taking a blood thinner?___________________________________________________

Diagnostic Studies:

X-Ray Yes No MRI Scan Yes No

CT Scans Yes No Bone Scan Yes No

EMG/NCS Yes No Other _____________

Past Medical History:

Cardiac High Blood Pressure Congestive Heart Failure Heart Attack Angina/Chest Pain

Coronary Artery Disease Irregular Heartbeat Heart Murmur Cardiac Stents

Pacemaker /AICD Blood Thinners Valvular Disease Vascular Disease

Pulmonary

COPD Emphysema Asthma Lung Cancer Sleep Apnea Bronchial Disease Tobacco

Renal Dialysis Renal Insufficiency Kidney Stone Prostate Problems

Neurological

Stroke Transient Ischemic Attack Seizures Nerve Damage

Infectious Valley Fever Tuberculosis HIV/AIDS Polio

Hepatic Liver Disease Cirrhosis Hepatitis Gall Bladder

If you have Hepatitis, please specify what type (if known):_____________________________

Gastrointestinal Hiatal Hernia GERD Gastric Ulcers Colitis

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Endocrine Thyroid Disease Parathyroid Disease Diabetes Mellitus

Psychological Depression Bipolar Addiction Schizophrenia

General

Anemia/Bleeding Arthritis Obesity Alcoholism

Past Surgical History (be as specific as possible, including surgery type and year of

surgery):

1. _________________________2.______________________3._______________________

4. _________________________5.______________________6._______________________

Serious Injury: List serious injuries you have sustained: _______________________________________________

Allergies to Medications: Yes No (if yes, indicate below drug and reaction)

Drug Reaction

_________________________ ___________________________

_________________________ ___________________________

_________________________ ___________________________

Current Medications (Include vitamins, antacids, birth control, etc., attach list if necessary):

Name: Dose: How often:

1. ______________________ ______________________ ________________

2. ______________________ ______________________ ________________

3. ______________________ ______________________ ________________

4. ______________________ ______________________ ________________

5. ______________________ ______________________ ________________

6. ______________________ ______________________ ________________

Family History: __________________________________________________________

Is there any history of drug/alcohol abuse/addiction in your family? Yes No

Social History:

Occupation: _______________________________________________________

Are you currently working? Yes No Part-time Full-time

Education: Elementary High school College Graduate school

Marital Status: Married Widowed Divorced Single Significant Other Children: Y/N If yes, how many? _________

Do you have any lawsuits pending or planned? Yes No

Are you on disability? Yes No Workmen’s Comp? Yes No

Tobacco use: Current Former Never

If current: #of packs per day __________ How many years? ________

Alcohol: Do you consume alcohol? Yes No

If Yes: Approximate #of drinks per day _________ How many years?________

Illicit/Street Drugs: Do you use any illicit/street drugs? Current Former Never

If current/former: What drugs?_________________________________________

Have you ever been in treatment for drug or alcohol problems? Yes No

Do you currently use Medical Marijuana? Yes No

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Review of Systems (List only current or very recent symptoms):

General: Weight Change Fatigue Weakness

Fever Loss of Appetite Chills

No Problems

Cardiac: Chest pain/Angina Shortness of Breath Palpitations

Peripheral Edema No problems

Endocrine: Heat intolerance Excessive sweating Excessive

urination

Cold intolerance Excessive thirst No problems

Gastrointestinal: Diarrhea Reflux Constipation

Change in appetite Abdominal pain Nausea

Loss of bowel control Blood or Black Stool Vomiting

No Problems

Genitourinary: Difficulty Urinating Painful Urination Blood in urine

Loss of Bladder Control No Problems

HEENT: Sinus Problems Difficulty Swallowing Headache

Jaw Problems Dry Mouth Migraines

Mouth Problems No Problems

Hematology/ Chemotherapy History Bleeding Disorder No Problems

Oncology: Radiation History Anticoagulation Therapy

Musculoskeletal: Muscle Cramps Joint Stiffness Muscle atrophy

Joint Redness Joint Swelling No Problems

Joint Heat

Neurological: Blackouts Weakness Numbness

Fainting Paralysis Gait Difficulties

Hallucinations Dizziness No Problems

Tremors Confusion

Opthalmology: Blurred Vision Eye Pain No Problems

Double Vision Photophobia (light is painful)

Psychiatric: Depression Suicidal Ideation Anxiety

Drug Abuse Homicidal Ideation No Problems

Respiratory: Cough Shortness of Breath Wheezing

Hemoptysis No Problems

Skin: Dry Skin Changes in Hair or Nail Eczema

Changes in Skin Color Recurrent Rashes No Problems

Itching

Toxins: Asbestos Industrial Chemicals Lead

Pesticides Drug Use No Problems

___________________________________ _____/_____/_____

Patient Signature Date

Reviewed by: _________________________ _____/_____/_____

Provider Signature Date

PATIENT REGISTRATION FORM Date_________________

Patient’s Name__________________________________________________________________________________

Address________________________________________________________________________________________

City _______________________State ________Zip Code____________ email ______________________________

Home Phone (___) _______________ Mobile (___) __________________ Work Phone (___) __________________

Social Security #___________________________ Date of Birth______________ Sex _____Marital Status_________

Referring Physician__________________________________________________Phone_______________________

Primary Care Physician_______________________________________________Phone_______________________

Patient’s Employer _______________________________________________________________________________

Employer Address________________________________________________________________________________

Responsible Party Information Self _____ Spouse _____ Parent ______ Other ______

Guarantor’s Name________________________________________________________________________________

Address________________________________________________________________________________________

City _______________________State ________Zip Code____________

Home Phone (___) _______________ Mobile (___) __________________ Work Phone (___) __________________

Relationship to Patient _______________Date of Birth _______________Social Security #______________________

Guarantor’s Employer ____________________________________Work Phone (______) _______________________

Employer Address_______________________________________________________________________________

Emergency Contact Information Name______________________________________________________________Relationship__________________ Address________________________________________________________________________________________ Home Phone (___) _______________ Mobile (___) __________________ Work Phone (___) __________________

Insurance Information

Primary Carrier: Name ______________________________________________Group #_____________________________

Address__________________________________________________________________________

Policy Holder’s Name _________________________________Relationship to Patient__________________

Policy Holder's Date of Birth______________________ Social Security #_______________________

Policy #_____________________________________

Secondary Carrier: Name ____________________________________________Group #_______________________________

Address_________________________________________________________________________________

Policy Holder's Name __________________________________Relationship to Patient_________________

Policy #______________________________________ Policy Holder’s Date of Birth____________________

Workmen’s Comp: Carrier__________________________________________________________________________________

Address_________________________________________________________________________________

Date of Injury __________________________________Claim #___________________________________

Claim Representative _____________________________Phone (______) ____________________________

Employer________________________________________________________________________________

PATIENT DEMOGRAPHICS In order to participate in federal and state healthcare programs, our practice requests the demographic information below. The terms below are the federal government's standards for classification of race and ethnicity.

Race (please check one box) American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American. A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. More than one race I prefer to not provide this information Ethnicity (please check one box) Hispanic or Latino Not Hispanic or Latino Undefined I prefer to not provide this information

Preferred Language (please check one box) Spanish English Other (please list) _________________ I prefer to not provide this information

AUTHORIZATION AND RELEASE

I authorize the release of any Protected Health Information including the diagnosis and the records of any treatment

rendered to my child or me during the period of such care to third party payers and/or other health practitioners.

I authorize and request my insurance company to pay directly to Valley Pain Consultants insurance benefits otherwise payable to me.

I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of services rendered on my behalf or my dependents.

______________________________________ Date: _______________________ Signature of Patient or Parent, if a minor ______________________________________ Printed Name of Patient / Minor

CONSENT TO RELEASE INFORMATION TO FAMILY

I hereby give my consent to release Protected Health Information from my medical and/ or financial records from Valley Pain Consultants to whomever requests it and identifies themselves as an immediate family member, including spouse, sibling, children, grandchildren, and anyone specifically listed below.

________________________________ ____________________________

I specifically DENY permission to release information to anyone without my written consent.

______________________________________ ________________________ Signature of Patient or Parent, if a minor Date

Printed name of Patient/ Minor ______________________________________ Printed name of Patient/Minor

CONSENT TO RELEASE INFORMATION TO PHYSICIAN I hereby give consent to release Protected Health Information regarding my treatment and/or copies of my medical record to my referring physician and/or primary care physician as listed on the Patient Registration Sheet.

___________________________________________ _________________________ Signature of Patient or Parent, if a minor Date

_______________________________________ Printed Name of Patient/ Minor

CONSENT TO TREAT

I further authorize and consent to the Practice’s physicians and their assistants and other Practice professional staff providing outpatient medical treatment, supplies, services, equipment and other items related to my healthcare to me as determined to be necessary in their professional judgment. I have been informed of the nature and purpose of the treatment, and potential common side effects thereof, as well as alternative treatment modalities, the approximate estimated duration of my healthcare, and that I am able to withdraw my consent for treatment either orally or in writing whether prior to or during the anticipated treatment period. ________________________________________ _____________________________ Signature of Patient or Parent, if a minor Date

________________________________________

Printed Name of Patient/Minor

I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. Valley’s Notice of Privacy Practices explains the process for revocation, which includes a request in writing. Unless I revoke this authorization earlier, this Consent for Release of Protected Health Information will remain in effect until terminated by me in writing.

Dear Patient _________________________, Due to all of the various HMO and PPO insurance plans now available in the marketplace, it has become a very complicated process to become familiar with each plan. All of the various companies and plans have their individual requirements for various procedures. It has therefore become necessary to request that all patients provide all information needed from their insurance company, and that they assume responsibility for providiing this information to our office, and to any other health facility involved in their particular treatment or illness, including hospitals. Patients must also notify their insurance company of any changes in their care or treatment so that proper handling and payment will be made by their insurance company. You may receive a pre-certification or authorization number from your insurance company. Please remember that this does not guarantee that your insurance company will pay for the procedure. It is your responsibility to call your insurance benefits department to see if you have any pre-existing or routine testing clauses in your contract which would prevent your insurance company from paying the bill. We have always filed and will continue to file claims for patients, but you must share equal responsibility for obtaining and giving the doctor or insurance company the necessary information needed to get your claim processed and paid within a reasonable time period. We realize that patients are not always given all the information required by their insurance company or agent, but it is still your responsibility to call and obtain this information before receiving treatment and before filing claims for treatment. We cannot emphasize enough how important this is, in order for you to receive the proper benefit you are entitled to under your insurance plan or contract. We are requesting your cooperation so that we may better serve you and give you the health care you deserve, without having to spend an exorbitant amount of time dealing with your insurance company. You should have and know all the information required by your individual plan(s) of insurance to avoid any confusion on your behalf of what services are covered by your insurance policie(s). Thank you for your cooperation. _____________________________________________ ______________ Patient Signature or Parent of Minor Date

CONSENT FOR THE USE OR RELEASE OF PROTECTED HEALTH INFORMATION

FOR TREATMENT PAYMENT OF HEALTHCARE OPERATIONS

As set forth more fully in our Notice of Privacy Practices, we are permitted to obtain your consent for any use or disclosure of your health information to carry out treatment, payment, or health care operations. In our Notice of Privacy Practices, we provide you information about how this office can use or disclose your health information. You have a right to review our Notice of Privacy Practices before signing this Consent. The Notice is available on our website or a brochure can be obtained at the front desk. We reserve the right to change the terms of our Notice of Privacy Practices at any time. If you have any questions related to the notice, you may contact Valley’s Privacy Officer, Dean F. Smith III, MD, or Patricia Durlam, RN, MAOM, Practice Administrator at 1850 N. Central Avenue, Suite 1600, Phoenix, AZ 85004 (telephone: 602.262.8903). By signing this form below, you consent to our use and disclosure of your health information for treatment, payment or health care operations. You have the right to request that we restrict how your health information is used or disclosed to carry out treatment, payment or health care operations. We are not required to agree with your requested restrictions; however, if we do agree to your restrictions, we are bound to follow them. I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. Valley’s Notice of Privacy Practices explains the process for revocation, which includes a request in writing. Unless I revoke this authorization earlier, this Consent for Release of Protected Health Information will remain in effect until terminated by me in writing. I understand that information in my health record may include information relating to Sexually Transmitted Disease, Acquired Immunodeficiency Syndrome (AIDS), Human Immunodeficiency Virus (HIV) and other communicable diseases, Behavioral Health Care/Psychiatric Care, treatment of alcohol and/or drug abuse. My signature authorizes release of information as it pertains to authorization or billing needs. ________________________________ _____________ Signature of Patient or Legal Representative Date If signed by Legal Representative, please describe the authority of Legal Representative to sign for patient: _______________________________ o I have received a copy of the Notice of Privacy Practices Yes __ No __ Initials ___ o I have declined a copy of the Notice of Privacy Practices Yes __ No __ Initials ___

EXPECTATIONS OF PATIENT/CAREGIVER

The following statements are expectations that we as a practice would like you to be informed. Once signed, you as a patient/caregiver acknowledge understanding of these policies and are aware that any violation of these policies may result in discharge from our practice. I_________________ understand that the medications I may receive from this practice are provided for their therapeutic value; however, they may have serious side effects. These side effects may be accentuated by the concurrent use of other medications and/or alcohol. It is unsafe to combine any medications and/or alcohol without first consulting with my physician. I also understand that I will need to take steps to prevent any pregnancy while on these medications due to the potential impact on the fetus. I understand that any medication that I receive from this practice may affect my ability to operate a motor vehicle, boat, or heavy machinery. I am accountable for determining whether my ability to do these things is impaired. I will be solely accountable for my decision regarding this as outlined under Arizona State Law, Title 28, Chapter 4, Article 3: “It is unlawful for a person to drive or be in actual physical control of a vehicle in this state under the influence of intoxicating liquor, and drug, a vapor releasing substance containing a toxin or any combination of liquor, drugs, or vapor releasing substances if the person is impaired to the slightest.” In Arizona, this may be grounds for prosecution of a Driving While Intoxicated (DWI)offense.________ initials) I am expected to be respectful of the physicians and staff, and I understand that inappropriate behavior will not be tolerated and may result in my dismissal from the Valley Pain Consultants practice. Patient Signature__________________________ Date ______________

DIRECT FINANCIAL INTEREST DISCLOSURE STATEMENT

State law, A.R.S. 32-1401 (25)(ff), requires that a physician notify a

patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient

and/or in the non-routine goods or services being prescribed by the physician, and whether these are available elsewhere on a competitive basis.

(I/We) support this law, because it helps patients make reasoned financial decisions concerning their medical care.

In compliance with the requirements of this law,please be advised that we

have a direct financial interest in the following Surgical Centers:

Gateway Surgery Center

Honor Health Pain Center

Metro Surgery Center North Valley Ambulatory Surgery Center (Honor Health)

North Scottsdale Ambulatory Surgery Center Paramount Surgery Center (Honor Health)

_____________________________ _________________ NAME DATE

Permission to Pick-up Prescriptions

I __________________________________ give permission for the following person(s) to pick up my prescriptions on my behalf: ________________________________________________________

(Name(s) of authorized person(s) I understand that no one other than the above listed person(s) will be able to pick up my prescriptions. I understand that if something should happen to the prescriptions while in the possession of the listed person(s), I am still fully responsible. This consent is good for one year from date signed unless you notify the office in writing of a change. Patient Signature _______________________________ Date __________ Staff Initials ______ Date __________