Forms Select Forms Based On Location Gilbert Forms Gilbert Groupon New Patient Packet Pain and Wellness of ArizonaName* Date of Birth MM slash DD slash YYYY Date of Birth DD slash MM slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Phone*Sex Email* Do you have insurance? YES NO Circle One BCBS Aetna UHC Cigna AHCCCS/Medicare Other Insurance ID# Policy Holder Occupation Employer Check any of the following symptoms you have experienced. 1. Low Back Pain 2. Neck Pain 3. Pain Between Shoulder Blades 4. Auto Accident (last 3 months) 5. Tension / Headaches 6. Migraines 7. Mid Back Pain 8. Pulled or Cramping Muscles 9.Bunions 10. Groin Pull 11. Shoulder Pain 12. Hip Pain 13. “Pinched Nerve” 14. Tension Across the Top of Shoulders 15. Tingling/Numbness in Arms or Hands 16. Tingling/Numbness in Legs or Feet 17. Foot Pain / Plantar Fasciitis 18. Poor Posture 19. Hand Pain 20. Hamstring Pull 21. Wrist / Carpal Tunnel 22. Arthritis 23. Rotator Cuff 24. TMJ (clicking or painful jaw) 25. Poor Flexibility 26. Fibromyalgia 27. Knee Pain 28. Asthma 29. Shin Splints 30. Golfer’s Elbow / Tennis Elbow Which of the above symptoms is the worst? How long have you had it? What is your pain today on a 1-10 scale with 10 being the worst?12345678910Pains are: Sharp Dull/ Ache Constant Intermittent Other Does this pain shoot, radiate, or travel in your body? Where? Are you experiencing numbness or tingling in any area of your body? Where? Since it began, is it Same Better Worst What activities aggravate your condition/pain? What activities lessen your condition/pain? Is this condition worse during certain times of the day? Is this condition interfering with Work? Sleep? Routine? Other? Is this condition progressively getting worse? Other Doctors seen for this condition Any home remedies? IF NO PLEASE SIGN (Included with First visit NO extra charge) HiddenGroupon / Referral HiddenDay1 Have you ever received Chiropractic Care? YES NO WOULD YOU LIKE TO RECEIVE X-RAYS TODAY? YES NO HiddenName HiddenDate DD slash MM slash YYYY Hospitalizations? YES NO Injuries during sports? YES NO Auto accidents? YES NO Did you have other traumas? YES NO Did you ever break any bones? YES NO Drive? Daily time spent driving YES NO Do you sleep well, hours of sleep? YES NO Did/do you smoke? YES NO Did/do you drink alcohol? YES NO Drugs, prescription, OTC, recreational? YES NO Exercise regularly? YES NO Diet, do you eat healthy foods? YES NO Physical, Emotional/Mentalstress? YES NO Sleeping posture? Side Stomach Back Other Symptoms Lights Bother Eyes Sleeping Problems Shortness of Breath Loss of Smell or Taste Ringing in Ears High Blood Pressure Heartburn/Reflux Loss of Memory Menstrual Cramps Jaw/TMJ Problems Loss of Balance Painful Urination Nervousness Joint Swelling Heart Attack Stomach Upset Weight Loss Irritability Depression Menopause Cold Hands Constipation Chest Pains Neck Stiff Dizziness Allergies Diarrhea Cold Feet Tension Cancer Diabetes Fatigue Stroke Fever Asthma Sinus Are you under medical care for any condition? What Medications are you taking? Have you had any surgeries? Where and When Females only: Date last menstrual period began Are you possibly Pregnant? I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation.I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation.I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation.I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation.I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation.Consent/Waiver of Liability: I consent to a massage provided by an independent massage therapist. I hold Pain and Wellness of Arizona harmless and agree that there shall be no liability on the part of Pain and Wellness of Arizona in any way related to the massage.Sign here Type your name here this will serve as your electronic signatureDate MM slash DD slash YYYY Informed Consent The nature of the chiropractic manipulation: I will use either my hands as an instrument or both to move the joints of your body; this may result in an audible “pop” or “click”.The material risks inherent in an adjustment: As with any healthcare procedure, there are certain complications that may arise during chiropractic manipulation. This may include strains, dislocations, fractures, disc injuries, and stroke. This list is not all-inclusive.The probability of those risks: Fractures are rare and can result from an underlying weakness in the bones. The other complications listed are considered rare. One source states that stroke is a possible occurrence in 1/1,000,000 cases or higher, even so, we employ tests during our examination to identify if you may be susceptible to that kind of injury.Ancillary treatments recommended: Ice, Moist Heat Packs, Electrical Muscle Stimulation, Stretching/Strengthening Exercises, Massage Therapy, Neuromuscular Re-education, and Mechanical TractionRisks involved with the recommended ancillary treatments: Ice and Electrical Muscle Stimulation (EMS) can cause burning. The EMS can cause skin irritation underneath the active pads. Stretching/Strengthening Exercises and Mechanical Traction can cause temporary post-treatment soreness or reflex muscle spasms. This list is not all-inclusive.Other treatment options for your condition can include: Medical care with prescription drugs, self-management with over-the-counter medication, rest, and/or surgery. There are material risks inherent in each of these options including but not limited to: addiction to medication, side effects of medication, improper self dosages, and surgical risks including complications from either the procedure and anesthesia.DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE I have read or have had read to me the above explanation of the chiropractic adjustment and the related treatment. I have discussed it with the doctor and have had my questions answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment. Sign here Type your name here this will serve as your electronic signatureDate MM slash DD slash YYYY Groupon New patient packet Gilbert Medical new patient packet Pain and Wellness of Arizona Name: Date of Birth: MM slash DD slash YYYY Today’s Date: MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Email PhoneHidden Home Mobile Work Emergency Contact:Relationship: Phone:Insurance Company: Insurance ID# Policy Holder: Pharmacy: Cross Streets: Phone Number:Onset of Symptoms and Reason for Visit Today: When did this pain begin? What caused your current pain or injury? Was the pain or injury due to a motor vehicle accident or personal injury? No Yes What is your current pain level right now? What is your worst level of pain level? Where is your worst area of pain located? Does the pain radiate? If yes, where? Please list additional areas of pain What word best describes the frequency of your pain? Constant Intermittent Since your pain began, has your pain Increased Decreased Stayed the Same When is your pain at its worst? Mornings During the Day Evenings Middle of Night Describe your pain today:Check all that apply Aching Cold Cramping Dull Hot/Burning Numb Shock-like Shooting Spasms Squeezing Stabbing/Sharp Throbbing Tingling/Pins and Needles Tiring/Exhausting Factors that Affect your Pain: Do you have significant back/buttock/leg pain with prolonged standing and/or prolonged walking that is relieved with sitting and/or lying down? No Yes If yes to the above question, is your pain also alleviated with bending forward (using a shopping cart, leaning on kitchen counter, etc.? No Yes Please indicate any factors that affect your pain in the list below: Bending Backward Increases Pain Decreases Pain No Change Bending Forward Increases Pain Decreases Pain No Change Changes in Weather Increases Pain Decreases Pain No Change Climbing Stairs Increases Pain Decreases Pain No Change Cold Increases Pain Decreases Pain No Change Coughing/Sneezing Increases Pain Decreases Pain No Change Heat Increases Pain Decreases Pain No Change Lifting Objects Increases Pain Decreases Pain No Change Looking Forward Increases Pain Decreases Pain No Change Looking Downward Increases Pain Decreases Pain No Change Looking Side to Side Increases Pain Decreases Pain No Change Lying Down Increases Pain Decreases Pain No Change Rising from a Seated Position Increases Pain Decreases Pain No Change Sitting Increases Pain Decreases Pain No Change Standing Increases Pain Decreases Pain No Change Walking Increases Pain Decreases Pain No Change Activity: How many days per week do you exercise? Type of Exercise Does your pain interfere with any of the following? Work School Home duties Daily living Recreational Activities Diagnostic Tests & Imaging - Mark all of the following tests you have had related to your current pain: MRI of the Date: MM slash DD slash YYYY Facility: CT scan of the Date: MM slash DD slash YYYY Facility: EMG/NCV study Date: MM slash DD slash YYYY Facility: Other Current Medications: Are you taking a prescribed blood-thinner? if so, which one? Name/phone of the doctor that prescribes your blood thinner: Please list ALL medications you are currently taking including OTC medications, ibuprofen, aspirin and fish oil. Attach additional sheet if necessary. 1. Medication Name Dose Frequency 2. Medication Name Dose Frequency 3. Medication Name Dose Frequency 4. Medication Name Dose Frequency 5. Medication Name Dose Frequency 6. Medication Name Dose Frequency 7. Medication Name Dose Frequency 8. Medication Name Dose Frequency 9. Medication Name Dose Frequency 10. Medication Name Dose Frequency Allergies Please list all allergies that you have Medication Name that I’m Allergic to:1. 2. The Allergic Reaction I have is: 1. 2. Are you allergic to any of the following? Iodine No Yes Tape No Yes Latex No Yes Do you require special rescue measures for your latex allergy? No Yes I HAVE NO KNOWN ALLERGIES Past Medical History /Problem List Are you currently pregnant? No Yes Do you plan on becoming pregnant? No Yes Mark all conditions/diseases that you have been DIAGNOSED with: Asthma Cancer, type Diabetes, type Emphysema/COPD Epilepsy Fibromyalgia Heart Disease Hepatitis, type HIV/AIDS High Blood Pressure Kidney Disease Lupus Migraines Osteoarthritis/Osteoporosis Peripheral Vascular Disease Shingles Sleep Apnea Stroke Other: I HAVE NO SIGNIFICANT MEDICAL HISTORY Past Surgical History Do you currently have an implanted ICD, pacemaker, or defibrillator? No Yes Please list prior surgeries or procedures in the table below. Attach an additional sheet if required.Date MM slash DD slash YYYY Surgery/Procedure Physician Date MM slash DD slash YYYY Surgery/Procedure Physician Date MM slash DD slash YYYY Surgery/Procedure Physician Date MM slash DD slash YYYY Surgery/Procedure Physician I HAVE NO SIGNIFICANT SURGICAL HISTORY Family History - Mark all appropriate diagnoses as they pertain to your BIOLOGICAL family members only. Anxiety/Depression Kidney Problems Diabetes Seizures High Blood Pressure Cancer Rheumatoid Arthritis Heart Disease/Stroke Arthritis Liver Problems Headaches Substance Abuse I HAVE NO SIGNIFICANT FAMILY MEDICAL HISTORY I AM ADOPTED (No Medical History Available) Social History Smoking: Current every day Current some days Former smoker Never smoker Alcohol: Current alcoholism History of alcoholism Social alcohol use No alcohol use Marijuana: Current use Former use Medical Marijuana Card Holder Never used Illegal Drugs: Current use Former use Never used list which ones list which ones Review of Systems - Mark all of the following symptoms that you CURRENTLY suffer from: Constitutional: Chills Difficulty Sleeping Fatigue Fevers Night Sweats Cardiovascular/Respiratory: Chest Pain Cough Difficulty Breathing Fainting High Blood Pressure Swelling in the Feet Gastrointestinal: Constipation Dark and Tarry Stools Diarrhea Nausea/Vomiting Genitourinary/Nephrology: Blood in Urine Involuntary Urination Loss of Bowel Control Painful Urination Pelvic Pressure Ears/Nose/Throat/Neck: Difficulty Hearing Earaches Hay fever/Allergies Nosebleeds Recurrent Sore Throats Ringing in the Ears Sinus Problems Eyes: Recent Visual Changes Neurological: Dizziness Headaches Instability When Walking Numbness/Tingling Weakness Psychiatric: Anxiety/Stress Depressed Mood Suicidal Thoughts Suicidal Planning Musculoskeletal: Back Pain Joint Pain Neck Pain To the best of my knowledge. The questions on this form have been accurately answered. It is my responsibility to inform the office of any changes in my medical status.Sign Here Type your name here this will serve as your electronic signature.Office Policies Here at Pain & Wellness of Arizona we strive on keeping our appointments on time for both our patients and provider. In order to keep our providers on schedule and the wait time for our patients as little as possible, we do not take late appointments. By signing below, you understand that if you are more than 10 minutes late to any appointment, you will not be seen and will need to re-schedule. Follow through with your care plan for the best results. If you have questions regarding your treatment plan please ask to meet with the Staff as soon as possible. Please turn your cell phones off while in our office, if you need to answer your phone please step outside. Pain and Wellness of Arizona, nor its staff will be responsible for the loss or damage to items brought into the facility, including but not limited to; glasses, dentures, hearing aids, contact lens, jewelry, money, wallets, purses, or any other personal item. The Privacy Rule allows you to receive a copy of your personal medical and billing records and allows the Practice to require individuals to complete and sign an Authorization for Disclosure and Release of Medical Records Form. The Practice will respond (at the provider’s discretion) to requests for the completion of certain medical forms (FMLA, Short Term Disability & Temporary Disability Parking Permit) assuming the patient is in good standing and has been active with the Practice for 1 month consecutively. All requests require an office visit. By signing you have read and agree with the office policies for Pain and Wellness of Arizona. Sign Here Type your name here this will serve as your electronic signature.Date MM slash DD slash YYYY General Consent and Authorization for treatment, Evaluation, and Information Release This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. The consent will remain fully effective until revoked in writing. You have the right to discontinue services at any time. ------------------------------------------------------------------------------------------------------------ I certify that my Medical History is complete and accurate to the best of my knowledge and ability. I understand this will become part of my medical history. I voluntarily request that Pain and Wellness of Arizona provide medical care, treatment, and services to me, as deemed reasonable and necessary by the assigned healthcare provider(s). I consent to reasonable and necessary medical examination, evaluation, testing and treatment which may include diagnostic, radiology and laboratory procedures. If invasive interventional treatment is recommended, I will be informed of the benefits and risks prior to performance of such treatment and will be provided with a separate consent form outlining such benefits and risks. RELEASE OF INFORMATION I specifically authorize the uses and discloser of my health information as described in the Notice of Privacy Practices provided to me. I authorize Pain and Wellness of Arizona, and/or their staff, to obtain my medication history and other relevant health care information, verbally, written, or electronically, that is deemed necessary for my treatment. I consent to release my health information to insurance companies, employers or other organizations responsible for payment of services, as appropriate. I understand this may include information relating to my diagnosis, care, payment for my care, or demographic information. BY SIGNING BELOW, I AM AGREENG TO THE CONSENTS AND RELEASES DESCRIBED ON THIS FORM. I HAVE READ THIS CONTENT AND HAVE BEEN ABLE TO ASK QUESTIONS. Sign Here Type your name here this will serve as your electronic signature.Relationship to Patient Date MM slash DD slash YYYY ADVANCED DIRECTIVE An “Advance Directive” is a general term that refers to your oral/written instructions about your future medical care, in the event that you become unable to speak for yourself. Each state regulates the use of the advance directive differently. There are two types of advance directives: a living will and a medical power of attorney. If you would like a copy of the Official AZ state advance directive forms, please visit www.azsos.gov/adv_dir/. Do you have an executed Advance Directive/Living Will? If yes please provide a copy to Pain and Wellness of Arizona. Yes No Do you have an executed Health Care Power of Attorney? If yes please provide a copy to Pain and Wellness of Arizona. Yes No Notice of Privacy Practice THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. At Pain & Wellness of Arizona, we are committed to treating and using your protected health information responsibly.This notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 2003, and applies to all protected health information as defined by federal regulations. Understanding Your Health Record/Information Each time you are seen by Pain & Wellness of Arizona, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a: Basis for planning your care and treatment, Means of communication among the many health professionals who contribute to your care, Legal document describing the care you received, Means by which you or a third-party payer can verify that services billed were actually provided, A tool in educating heath professionals, A source of data for medical research, A source of information for public health officials charged with improving the health of this state and the nation, • A source of data for our planning and marketing, A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve, Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others Your Health Information Rights Although your health record is the physical property of Pain & Wellness of Arizona, the information belongs to you. You have the right to: Obtain a paper copy of this notice of information practices upon request, Inspect and copy your health record as provided for in 45 CFR 164.524, Amend your health record as provided in 45 CFR 164.528, Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528, Request communications of your health information by alternative means or at alternative locations, Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and Revoke your authorization to use or disclose health information except to the extent that action has already been taken. Examples of Disclosures for Treatment, Payment and Health Operations We will use your health information for treatment: For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you’re discharged from this hospital. We will use your health information for payment: For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. Business associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, billing services, and a copy service we may use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information. Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. Communication with family: Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. Funeral directors: We may disclose health information Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Pain & Wellness of Arizona, is required to: Maintain the privacy of your health information, Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you, Abide by the terms of this notice, Notify you if we are unable to agree to a requested restriction, and Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us, or if you agree, we will email the revised notice to you. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer at 480-3604444, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is:Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201 New Medical Patient Packet North Phoenix Forms North Phoenix Groupon new patient packet Pain and Wellness of ArizonaName* Date of Birth MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Phone*Sex Email* Do you have insurance? YES NO Circle One BCBS Aetna UHC Cigna AHCCCS/Medicare Other Insurance ID# Policy Holder Occupation Employer Check any of the following symptoms you have experienced. 1. Low Back Pain 2. Neck Pain 3. Pain Between Shoulder Blades 4. Auto Accident (last 3 months) 5. Tension / Headaches 6. Migraines 7. Mid Back Pain 8. Pulled or Cramping Muscles 9.Bunions 10. Groin Pull 11. Shoulder Pain 12. Hip Pain 13. “Pinched Nerve” 14. Tension Across the Top of Shoulders 15. Tingling/Numbness in Arms or Hands 16. Tingling/Numbness in Legs or Feet 17. Foot Pain / Plantar Fasciitis 18. Poor Posture 19. Hand Pain 20. Hamstring Pull 21. Wrist / Carpal Tunnel 22. Arthritis 23. Rotator Cuff 24. TMJ (clicking or painful jaw) 25. Poor Flexibility 26. Fibromyalgia 27. Knee Pain 28. Asthma 29. Shin Splints 30. Golfer’s Elbow / Tennis Elbow Which of the above symptoms is the worst? How long have you had it? What is your pain today on a 1-10 scale with 10 being the worst?12345678910Pains are: Sharp Dull/ Ache Constant Intermittent Other Does this pain shoot, radiate, or travel in your body? Where? Are you experiencing numbness or tingling in any area of your body? Where? Since it began, is it Same Better Worst What activities aggravate your condition/pain? What activities lessen your condition/pain? Is this condition worse during certain times of the day? Is this condition interfering with Work? Sleep? Routine? Other? Is this condition progressively getting worse? Other Doctors seen for this condition Any home remedies? IF NO PLEASE SIGN (Included with First visit NO extra charge) HiddenGroupon / Referral HiddenDay1 Have you ever received Chiropractic Care? YES NO WOULD YOU LIKE TO RECEIVE X-RAYS TODAY? YES NO HiddenName HiddenDate MM slash DD slash YYYY Hospitalizations? YES NO Injuries during sports? YES NO Auto accidents? YES NO Did you have other traumas? YES NO Did you ever break any bones? YES NO Drive? Daily time spent driving YES NO Do you sleep well, hours of sleep? YES NO Did/do you smoke? YES NO Did/do you drink alcohol? YES NO Drugs, prescription, OTC, recreational? YES NO Exercise regularly? YES NO Diet, do you eat healthy foods? YES NO Physical, Emotional/Mentalstress? YES NO Sleeping posture? Side Stomach Back Other Symptoms Lights Bother Eyes Sleeping Problems Shortness of Breath Loss of Smell or Taste Ringing in Ears High Blood Pressure Heartburn/Reflux Loss of Memory Menstrual Cramps Jaw/TMJ Problems Loss of Balance Painful Urination Nervousness Joint Swelling Heart Attack Stomach Upset Weight Loss Irritability Depression Menopause Cold Hands Constipation Chest Pains Neck Stiff Dizziness Allergies Diarrhea Cold Feet Tension Cancer Diabetes Fatigue Stroke Fever Asthma Sinus Are you under medical care for any condition? What Medications are you taking? Have you had any surgeries? Where and When Females only: Date last menstrual period began Are you possibly Pregnant? I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation.Consent/Waiver of Liability: I consent to a massage provided by an independent massage therapist. I hold Pain and Wellness of Arizona harmless and agree that there shall be no liability on the part of Pain and Wellness of Arizona in any way related to the massage.Sign here Type your name here this will serve as your electronic signatureDate MM slash DD slash YYYY Informed Consent The nature of the chiropractic manipulation: I will use either my hands as an instrument or both to move the joints of your body; this may result in an audible “pop” or “click”.The material risks inherent in an adjustment: As with any healthcare procedure, there are certain complications that may arise during chiropractic manipulation. This may include strains, dislocations, fractures, disc injuries, and stroke. This list is not all-inclusive.The probability of those risks: Fractures are rare and can result from an underlying weakness in the bones. The other complications listed are considered rare. One source states that stroke is a possible occurrence in 1/1,000,000 cases or higher, even so, we employ tests during our examination to identify if you may be susceptible to that kind of injury.Ancillary treatments recommended: Ice, Moist Heat Packs, Electrical Muscle Stimulation, Stretching/Strengthening Exercises, Massage Therapy, Neuromuscular Re-education, and Mechanical TractionRisks involved with the recommended ancillary treatments: Ice and Electrical Muscle Stimulation (EMS) can cause burning. The EMS can cause skin irritation underneath the active pads. Stretching/Strengthening Exercises and Mechanical Traction can cause temporary post-treatment soreness or reflex muscle spasms. This list is not all-inclusive.Other treatment options for your condition can include: Medical care with prescription drugs, self-management with over-the-counter medication, rest, and/or surgery. There are material risks inherent in each of these options including but not limited to: addiction to medication, side effects of medication, improper self dosages, and surgical risks including complications from either the procedure and anesthesia.DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE I have read or have had read to me the above explanation of the chiropractic adjustment and the related treatment. I have discussed it with the doctor and have had my questions answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment. Sign here Type your name here this will serve as your electronic signatureDate MM slash DD slash YYYY Groupon New patient packet North Phoenix Medical new patient packet Pain and Wellness of Arizona Name: Date of Birth: MM slash DD slash YYYY Today’s Date: MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Email PhoneHidden Home Mobile Work Emergency Contact:Relationship: Phone:Insurance Company: Insurance ID# Policy Holder: Pharmacy: Cross Streets: Phone Number:Onset of Symptoms and Reason for Visit Today: When did this pain begin? What caused your current pain or injury? Was the pain or injury due to a motor vehicle accident or personal injury? No Yes What is your current pain level right now? What is your worst level of pain level? Where is your worst area of pain located? Does the pain radiate? If yes, where? Please list additional areas of pain What word best describes the frequency of your pain? Constant Intermittent Since your pain began, has your pain Increased Decreased Stayed the Same When is your pain at its worst? Mornings During the Day Evenings Middle of Night Describe your pain today:Check all that apply Aching Cold Cramping Dull Hot/Burning Numb Shock-like Shooting Spasms Squeezing Stabbing/Sharp Throbbing Tingling/Pins and Needles Tiring/Exhausting Factors that Affect your Pain: Do you have significant back/buttock/leg pain with prolonged standing and/or prolonged walking that is relieved with sitting and/or lying down? No Yes If yes to the above question, is your pain also alleviated with bending forward (using a shopping cart, leaning on kitchen counter, etc.? No Yes Please indicate any factors that affect your pain in the list below: Bending Backward Increases Pain Decreases Pain No Change Bending Forward Increases Pain Decreases Pain No Change Changes in Weather Increases Pain Decreases Pain No Change Climbing Stairs Increases Pain Decreases Pain No Change Cold Increases Pain Decreases Pain No Change Coughing/Sneezing Increases Pain Decreases Pain No Change Heat Increases Pain Decreases Pain No Change Lifting Objects Increases Pain Decreases Pain No Change Looking Forward Increases Pain Decreases Pain No Change Looking Downward Increases Pain Decreases Pain No Change Looking Side to Side Increases Pain Decreases Pain No Change Lying Down Increases Pain Decreases Pain No Change Rising from a Seated Position Increases Pain Decreases Pain No Change Sitting Increases Pain Decreases Pain No Change Standing Increases Pain Decreases Pain No Change Walking Increases Pain Decreases Pain No Change Activity: How many days per week do you exercise? Type of Exercise Does your pain interfere with any of the following? Work School Home duties Daily living Recreational Activities Diagnostic Tests & Imaging - Mark all of the following tests you have had related to your current pain: MRI of the Date: MM slash DD slash YYYY Facility: CT scan of the Date: MM slash DD slash YYYY Facility: EMG/NCV study Date: MM slash DD slash YYYY Facility: Other Current Medications: Are you taking a prescribed blood-thinner? if so, which one? Name/phone of the doctor that prescribes your blood thinner: Please list ALL medications you are currently taking including OTC medications, ibuprofen, aspirin and fish oil. Attach additional sheet if necessary. 1. Medication Name Dose Frequency 2. Medication Name Dose Frequency 3. Medication Name Dose Frequency 4. Medication Name Dose Frequency 5. Medication Name Dose Frequency 6. Medication Name Dose Frequency 7. Medication Name Dose Frequency 8. Medication Name Dose Frequency 9. Medication Name Dose Frequency 10. Medication Name Dose Frequency Allergies Please list all allergies that you have Medication Name that I’m Allergic to:1. 2. The Allergic Reaction I have is: 1. 2. Are you allergic to any of the following? Iodine No Yes Tape No Yes Latex No Yes Do you require special rescue measures for your latex allergy? No Yes I HAVE NO KNOWN ALLERGIES Past Medical History /Problem List Are you currently pregnant? No Yes Do you plan on becoming pregnant? No Yes Mark all conditions/diseases that you have been DIAGNOSED with: Asthma Cancer, type Diabetes, type Emphysema/COPD Epilepsy Fibromyalgia Heart Disease Hepatitis, type HIV/AIDS High Blood Pressure Kidney Disease Lupus Migraines Osteoarthritis/Osteoporosis Peripheral Vascular Disease Shingles Sleep Apnea Stroke Other: I HAVE NO SIGNIFICANT MEDICAL HISTORY Past Surgical History Do you currently have an implanted ICD, pacemaker, or defibrillator? No Yes Please list prior surgeries or procedures in the table below. Attach an additional sheet if required.Date MM slash DD slash YYYY Surgery/Procedure Physician Date MM slash DD slash YYYY Surgery/Procedure Physician Date MM slash DD slash YYYY Surgery/Procedure Physician Date MM slash DD slash YYYY Surgery/Procedure Physician I HAVE NO SIGNIFICANT SURGICAL HISTORY Family History - Mark all appropriate diagnoses as they pertain to your BIOLOGICAL family members only. Anxiety/Depression Kidney Problems Diabetes Seizures High Blood Pressure Cancer Rheumatoid Arthritis Heart Disease/Stroke Arthritis Liver Problems Headaches Substance Abuse I HAVE NO SIGNIFICANT FAMILY MEDICAL HISTORY I AM ADOPTED (No Medical History Available) Social History Smoking: Current every day Current some days Former smoker Never smoker Alcohol: Current alcoholism History of alcoholism Social alcohol use No alcohol use Marijuana: Current use Former use Medical Marijuana Card Holder Never used Illegal Drugs: Current use Former use Never used list which ones list which ones Review of Systems - Mark all of the following symptoms that you CURRENTLY suffer from: Constitutional: Chills Difficulty Sleeping Fatigue Fevers Night Sweats Cardiovascular/Respiratory: Chest Pain Cough Difficulty Breathing Fainting High Blood Pressure Swelling in the Feet Gastrointestinal: Constipation Dark and Tarry Stools Diarrhea Nausea/Vomiting Genitourinary/Nephrology: Blood in Urine Involuntary Urination Loss of Bowel Control Painful Urination Pelvic Pressure Ears/Nose/Throat/Neck: Difficulty Hearing Earaches Hay fever/Allergies Nosebleeds Recurrent Sore Throats Ringing in the Ears Sinus Problems Eyes: Recent Visual Changes Neurological: Dizziness Headaches Instability When Walking Numbness/Tingling Weakness Psychiatric: Anxiety/Stress Depressed Mood Suicidal Thoughts Suicidal Planning Musculoskeletal: Back Pain Joint Pain Neck Pain To the best of my knowledge. The questions on this form have been accurately answered. It is my responsibility to inform the office of any changes in my medical status.Sign Here Type your name here this will serve as your electronic signature.Office Policies Here at Pain & Wellness of Arizona we strive on keeping our appointments on time for both our patients and provider. In order to keep our providers on schedule and the wait time for our patients as little as possible, we do not take late appointments. By signing below, you understand that if you are more than 10 minutes late to any appointment, you will not be seen and will need to re-schedule. Follow through with your care plan for the best results. If you have questions regarding your treatment plan please ask to meet with the Staff as soon as possible. Please turn your cell phones off while in our office, if you need to answer your phone please step outside. Pain and Wellness of Arizona, nor its staff will be responsible for the loss or damage to items brought into the facility, including but not limited to; glasses, dentures, hearing aids, contact lens, jewelry, money, wallets, purses, or any other personal item. The Privacy Rule allows you to receive a copy of your personal medical and billing records and allows the Practice to require individuals to complete and sign an Authorization for Disclosure and Release of Medical Records Form. The Practice will respond (at the provider’s discretion) to requests for the completion of certain medical forms (FMLA, Short Term Disability & Temporary Disability Parking Permit) assuming the patient is in good standing and has been active with the Practice for 1 month consecutively. All requests require an office visit. By signing you have read and agree with the office policies for Pain and Wellness of Arizona. Sign Here Type your name here this will serve as your electronic signature.Date MM slash DD slash YYYY General Consent and Authorization for treatment, Evaluation, and Information Release This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. The consent will remain fully effective until revoked in writing. You have the right to discontinue services at any time. ------------------------------------------------------------------------------------------------------------ I certify that my Medical History is complete and accurate to the best of my knowledge and ability. I understand this will become part of my medical history. I voluntarily request that Pain and Wellness of Arizona provide medical care, treatment, and services to me, as deemed reasonable and necessary by the assigned healthcare provider(s). I consent to reasonable and necessary medical examination, evaluation, testing and treatment which may include diagnostic, radiology and laboratory procedures. If invasive interventional treatment is recommended, I will be informed of the benefits and risks prior to performance of such treatment and will be provided with a separate consent form outlining such benefits and risks. RELEASE OF INFORMATION I specifically authorize the uses and discloser of my health information as described in the Notice of Privacy Practices provided to me. I authorize Pain and Wellness of Arizona, and/or their staff, to obtain my medication history and other relevant health care information, verbally, written, or electronically, that is deemed necessary for my treatment. I consent to release my health information to insurance companies, employers or other organizations responsible for payment of services, as appropriate. I understand this may include information relating to my diagnosis, care, payment for my care, or demographic information. BY SIGNING BELOW, I AM AGREENG TO THE CONSENTS AND RELEASES DESCRIBED ON THIS FORM. I HAVE READ THIS CONTENT AND HAVE BEEN ABLE TO ASK QUESTIONS. Sign Here Type your name here this will serve as your electronic signature.Relationship to Patient Date MM slash DD slash YYYY ADVANCED DIRECTIVE An “Advance Directive” is a general term that refers to your oral/written instructions about your future medical care, in the event that you become unable to speak for yourself. Each state regulates the use of the advance directive differently. There are two types of advance directives: a living will and a medical power of attorney. If you would like a copy of the Official AZ state advance directive forms, please visit www.azsos.gov/adv_dir/. Do you have an executed Advance Directive/Living Will? If yes please provide a copy to Pain and Wellness of Arizona. Yes No Do you have an executed Health Care Power of Attorney? If yes please provide a copy to Pain and Wellness of Arizona. Yes No Notice of Privacy Practice THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. At Pain & Wellness of Arizona, we are committed to treating and using your protected health information responsibly.This notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 2003, and applies to all protected health information as defined by federal regulations. Understanding Your Health Record/Information Each time you are seen by Pain & Wellness of Arizona, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a: Basis for planning your care and treatment, Means of communication among the many health professionals who contribute to your care, Legal document describing the care you received, Means by which you or a third-party payer can verify that services billed were actually provided, A tool in educating heath professionals, A source of data for medical research, A source of information for public health officials charged with improving the health of this state and the nation, • A source of data for our planning and marketing, A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve, Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others Your Health Information Rights Although your health record is the physical property of Pain & Wellness of Arizona, the information belongs to you. You have the right to: Obtain a paper copy of this notice of information practices upon request, Inspect and copy your health record as provided for in 45 CFR 164.524, Amend your health record as provided in 45 CFR 164.528, Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528, Request communications of your health information by alternative means or at alternative locations, Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and Revoke your authorization to use or disclose health information except to the extent that action has already been taken. Examples of Disclosures for Treatment, Payment and Health Operations We will use your health information for treatment: For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you’re discharged from this hospital. We will use your health information for payment: For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. Business associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, billing services, and a copy service we may use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information. Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. Communication with family: Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. Funeral directors: We may disclose health information Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Pain & Wellness of Arizona, is required to: Maintain the privacy of your health information, Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you, Abide by the terms of this notice, Notify you if we are unable to agree to a requested restriction, and Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us, or if you agree, we will email the revised notice to you. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer at 480-3604444, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is:Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201 New Medical Patient Packet Chandler Forms Chandler Groupon New Patient Packet Pain and Wellness of ArizonaName* Date of Birth MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Phone*Sex Email* Do you have insurance? YES NO Circle One BCBS Aetna UHC Cigna AHCCCS/Medicare Other Insurance ID# Policy Holder Occupation Employer Check any of the following symptoms you have experienced. 1. Low Back Pain 2. Neck Pain 3. Pain Between Shoulder Blades 4. Auto Accident (last 3 months) 5. Tension / Headaches 6. Migraines 7. Mid Back Pain 8. Pulled or Cramping Muscles 9.Bunions 10. Groin Pull 11. Shoulder Pain 12. Hip Pain 13. “Pinched Nerve” 14. Tension Across the Top of Shoulders 15. Tingling/Numbness in Arms or Hands 16. Tingling/Numbness in Legs or Feet 17. Foot Pain / Plantar Fasciitis 18. Poor Posture 19. Hand Pain 20. Hamstring Pull 21. Wrist / Carpal Tunnel 22. Arthritis 23. Rotator Cuff 24. TMJ (clicking or painful jaw) 25. Poor Flexibility 26. Fibromyalgia 27. Knee Pain 28. Asthma 29. Shin Splints 30. Golfer’s Elbow / Tennis Elbow Which of the above symptoms is the worst? How long have you had it? What is your pain today on a 1-10 scale with 10 being the worst?12345678910Pains are: Sharp Dull/ Ache Constant Intermittent Other Does this pain shoot, radiate, or travel in your body? Where? Are you experiencing numbness or tingling in any area of your body? Where? Since it began, is it Same Better Worst What activities aggravate your condition/pain? What activities lessen your condition/pain? Is this condition worse during certain times of the day? Is this condition interfering with Work? Sleep? Routine? Other? Is this condition progressively getting worse? Other Doctors seen for this condition Any home remedies? IF NO PLEASE SIGN (Included with First visit NO extra charge) HiddenGroupon / Referral HiddenDay1 Have you ever received Chiropractic Care? YES NO WOULD YOU LIKE TO RECEIVE X-RAYS TODAY? YES NO HiddenName HiddenDate MM slash DD slash YYYY Hospitalizations? YES NO Injuries during sports? YES NO Auto accidents? YES NO Did you have other traumas? YES NO Did you ever break any bones? YES NO Drive? Daily time spent driving YES NO Do you sleep well, hours of sleep? YES NO Did/do you smoke? YES NO Did/do you drink alcohol? YES NO Drugs, prescription, OTC, recreational? YES NO Exercise regularly? YES NO Diet, do you eat healthy foods? YES NO Physical, Emotional/Mentalstress? YES NO Sleeping posture? Side Stomach Back Other Symptoms Lights Bother Eyes Sleeping Problems Shortness of Breath Loss of Smell or Taste Ringing in Ears High Blood Pressure Heartburn/Reflux Loss of Memory Menstrual Cramps Jaw/TMJ Problems Loss of Balance Painful Urination Nervousness Joint Swelling Heart Attack Stomach Upset Weight Loss Irritability Depression Menopause Cold Hands Constipation Chest Pains Neck Stiff Dizziness Allergies Diarrhea Cold Feet Tension Cancer Diabetes Fatigue Stroke Fever Asthma Sinus Are you under medical care for any condition? What Medications are you taking? Have you had any surgeries? Where and When Females only: Date last menstrual period began Are you possibly Pregnant? I hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation.Consent/Waiver of Liability: I consent to a massage provided by an independent massage therapist. I hold Pain and Wellness of Arizona harmless and agree that there shall be no liability on the part of Pain and Wellness of Arizona in any way related to the massage.Sign here Type your name here this will serve as your electronic signatureDate MM slash DD slash YYYY Informed Consent The nature of the chiropractic manipulation: I will use either my hands as an instrument or both to move the joints of your body; this may result in an audible “pop” or “click”.The material risks inherent in an adjustment: As with any healthcare procedure, there are certain complications that may arise during chiropractic manipulation. This may include strains, dislocations, fractures, disc injuries, and stroke. This list is not all-inclusive.The probability of those risks: Fractures are rare and can result from an underlying weakness in the bones. The other complications listed are considered rare. One source states that stroke is a possible occurrence in 1/1,000,000 cases or higher, even so, we employ tests during our examination to identify if you may be susceptible to that kind of injury.Ancillary treatments recommended: Ice, Moist Heat Packs, Electrical Muscle Stimulation, Stretching/Strengthening Exercises, Massage Therapy, Neuromuscular Re-education, and Mechanical TractionRisks involved with the recommended ancillary treatments: Ice and Electrical Muscle Stimulation (EMS) can cause burning. The EMS can cause skin irritation underneath the active pads. Stretching/Strengthening Exercises and Mechanical Traction can cause temporary post-treatment soreness or reflex muscle spasms. This list is not all-inclusive.Other treatment options for your condition can include: Medical care with prescription drugs, self-management with over-the-counter medication, rest, and/or surgery. There are material risks inherent in each of these options including but not limited to: addiction to medication, side effects of medication, improper self dosages, and surgical risks including complications from either the procedure and anesthesia.DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE I have read or have had read to me the above explanation of the chiropractic adjustment and the related treatment. I have discussed it with the doctor and have had my questions answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment. Sign here Type your name here this will serve as your electronic signatureDate MM slash DD slash YYYY Groupon New patient packet Chandler New Patient Packet Name: Date of Birth: MM slash DD slash YYYY Today’s Date: MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Email PhoneHidden Home Mobile Work Emergency Contact:Relationship: Phone:Insurance Company: Insurance ID# Policy Holder: Pharmacy: Cross Streets: Phone Number:Onset of Symptoms and Reason for Visit Today: When did this pain begin? What caused your current pain or injury? Was the pain or injury due to a motor vehicle accident or personal injury? No Yes What is your current pain level right now? What is your worst level of pain level? Where is your worst area of pain located? Does the pain radiate? If yes, where? Please list additional areas of pain What word best describes the frequency of your pain? Constant Intermittent Since your pain began, has your pain Increased Decreased Stayed the Same When is your pain at its worst? Mornings During the Day Evenings Middle of Night Describe your pain today:Check all that apply Aching Cold Cramping Dull Hot/Burning Numb Shock-like Shooting Spasms Squeezing Stabbing/Sharp Throbbing Tingling/Pins and Needles Tiring/Exhausting Factors that Affect your Pain: Do you have significant back/buttock/leg pain with prolonged standing and/or prolonged walking that is relieved with sitting and/or lying down? No Yes If yes to the above question, is your pain also alleviated with bending forward (using a shopping cart, leaning on kitchen counter, etc.? No Yes Please indicate any factors that affect your pain in the list below: Bending Backward Increases Pain Decreases Pain No Change Bending Forward Increases Pain Decreases Pain No Change Changes in Weather Increases Pain Decreases Pain No Change Climbing Stairs Increases Pain Decreases Pain No Change Cold Increases Pain Decreases Pain No Change Coughing/Sneezing Increases Pain Decreases Pain No Change Heat Increases Pain Decreases Pain No Change Lifting Objects Increases Pain Decreases Pain No Change Looking Forward Increases Pain Decreases Pain No Change Looking Downward Increases Pain Decreases Pain No Change Looking Side to Side Increases Pain Decreases Pain No Change Lying Down Increases Pain Decreases Pain No Change Rising from a Seated Position Increases Pain Decreases Pain No Change Sitting Increases Pain Decreases Pain No Change Standing Increases Pain Decreases Pain No Change Walking Increases Pain Decreases Pain No Change Activity: How many days per week do you exercise? Type of Exercise Does your pain interfere with any of the following? Work School Home duties Daily living Recreational Activities Diagnostic Tests & Imaging - Mark all of the following tests you have had related to your current pain: MRI of the Date: MM slash DD slash YYYY Facility: CT scan of the Date: MM slash DD slash YYYY Facility: EMG/NCV study Date: MM slash DD slash YYYY Facility: Other Current Medications: Are you taking a prescribed blood-thinner? if so, which one? Name/phone of the doctor that prescribes your blood thinner: Please list ALL medications you are currently taking including OTC medications, ibuprofen, aspirin and fish oil. Attach additional sheet if necessary. 1. Medication Name Dose Frequency 2. Medication Name Dose Frequency 3. Medication Name Dose Frequency 4. Medication Name Dose Frequency 5. Medication Name Dose Frequency 6. Medication Name Dose Frequency 7. Medication Name Dose Frequency 8. Medication Name Dose Frequency 9. Medication Name Dose Frequency 10. Medication Name Dose Frequency Allergies Please list all allergies that you have Medication Name that I’m Allergic to:1. 2. The Allergic Reaction I have is: 1. 2. Are you allergic to any of the following? Iodine No Yes Tape No Yes Latex No Yes Do you require special rescue measures for your latex allergy? No Yes I HAVE NO KNOWN ALLERGIES Past Medical History /Problem List Are you currently pregnant? No Yes Do you plan on becoming pregnant? No Yes Mark all conditions/diseases that you have been DIAGNOSED with: Asthma Cancer, type Diabetes, type Emphysema/COPD Epilepsy Fibromyalgia Heart Disease Hepatitis, type HIV/AIDS High Blood Pressure Kidney Disease Lupus Migraines Osteoarthritis/Osteoporosis Peripheral Vascular Disease Shingles Sleep Apnea Stroke Other: I HAVE NO SIGNIFICANT MEDICAL HISTORY Past Surgical History Do you currently have an implanted ICD, pacemaker, or defibrillator? No Yes Please list prior surgeries or procedures in the table below. Attach an additional sheet if required.Date MM slash DD slash YYYY Surgery/Procedure Physician Date MM slash DD slash YYYY Surgery/Procedure Physician Date MM slash DD slash YYYY Surgery/Procedure Physician Date MM slash DD slash YYYY Surgery/Procedure Physician I HAVE NO SIGNIFICANT SURGICAL HISTORY Family History - Mark all appropriate diagnoses as they pertain to your BIOLOGICAL family members only. Anxiety/Depression Kidney Problems Diabetes Seizures High Blood Pressure Cancer Rheumatoid Arthritis Heart Disease/Stroke Arthritis Liver Problems Headaches Substance Abuse I HAVE NO SIGNIFICANT FAMILY MEDICAL HISTORY I AM ADOPTED (No Medical History Available) Social History Smoking: Current every day Current some days Former smoker Never smoker Alcohol: Current alcoholism History of alcoholism Social alcohol use No alcohol use Marijuana: Current use Former use Medical Marijuana Card Holder Never used Illegal Drugs: Current use Former use Never used list which ones list which ones Review of Systems - Mark all of the following symptoms that you CURRENTLY suffer from: Constitutional: Chills Difficulty Sleeping Fatigue Fevers Night Sweats Cardiovascular/Respiratory: Chest Pain Cough Difficulty Breathing Fainting High Blood Pressure Swelling in the Feet Gastrointestinal: Constipation Dark and Tarry Stools Diarrhea Nausea/Vomiting Genitourinary/Nephrology: Blood in Urine Involuntary Urination Loss of Bowel Control Painful Urination Pelvic Pressure Ears/Nose/Throat/Neck: Difficulty Hearing Earaches Hay fever/Allergies Nosebleeds Recurrent Sore Throats Ringing in the Ears Sinus Problems Eyes: Recent Visual Changes Neurological: Dizziness Headaches Instability When Walking Numbness/Tingling Weakness Psychiatric: Anxiety/Stress Depressed Mood Suicidal Thoughts Suicidal Planning Musculoskeletal: Back Pain Joint Pain Neck Pain To the best of my knowledge. The questions on this form have been accurately answered. It is my responsibility to inform the office of any changes in my medical status.Sign Here Type your name here this will serve as your electronic signature.Office Policies Here at Pain & Wellness of Arizona we strive on keeping our appointments on time for both our patients and provider. In order to keep our providers on schedule and the wait time for our patients as little as possible, we do not take late appointments. By signing below, you understand that if you are more than 10 minutes late to any appointment, you will not be seen and will need to re-schedule. Follow through with your care plan for the best results. If you have questions regarding your treatment plan please ask to meet with the Staff as soon as possible. Please turn your cell phones off while in our office, if you need to answer your phone please step outside. Pain and Wellness of Arizona, nor its staff will be responsible for the loss or damage to items brought into the facility, including but not limited to; glasses, dentures, hearing aids, contact lens, jewelry, money, wallets, purses, or any other personal item. The Privacy Rule allows you to receive a copy of your personal medical and billing records and allows the Practice to require individuals to complete and sign an Authorization for Disclosure and Release of Medical Records Form. The Practice will respond (at the provider’s discretion) to requests for the completion of certain medical forms (FMLA, Short Term Disability & Temporary Disability Parking Permit) assuming the patient is in good standing and has been active with the Practice for 1 month consecutively. All requests require an office visit. By signing you have read and agree with the office policies for Pain and Wellness of Arizona. Sign Here Type your name here this will serve as your electronic signature.Date MM slash DD slash YYYY General Consent and Authorization for treatment, Evaluation, and Information Release This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. The consent will remain fully effective until revoked in writing. You have the right to discontinue services at any time. ------------------------------------------------------------------------------------------------------------ I certify that my Medical History is complete and accurate to the best of my knowledge and ability. I understand this will become part of my medical history. I voluntarily request that Pain and Wellness of Arizona provide medical care, treatment, and services to me, as deemed reasonable and necessary by the assigned healthcare provider(s). I consent to reasonable and necessary medical examination, evaluation, testing and treatment which may include diagnostic, radiology and laboratory procedures. If invasive interventional treatment is recommended, I will be informed of the benefits and risks prior to performance of such treatment and will be provided with a separate consent form outlining such benefits and risks. RELEASE OF INFORMATION I specifically authorize the uses and discloser of my health information as described in the Notice of Privacy Practices provided to me. I authorize Pain and Wellness of Arizona, and/or their staff, to obtain my medication history and other relevant health care information, verbally, written, or electronically, that is deemed necessary for my treatment. I consent to release my health information to insurance companies, employers or other organizations responsible for payment of services, as appropriate. I understand this may include information relating to my diagnosis, care, payment for my care, or demographic information. BY SIGNING BELOW, I AM AGREENG TO THE CONSENTS AND RELEASES DESCRIBED ON THIS FORM. I HAVE READ THIS CONTENT AND HAVE BEEN ABLE TO ASK QUESTIONS. Sign Here Type your name here this will serve as your electronic signature.Relationship to Patient Date MM slash DD slash YYYY ADVANCED DIRECTIVE An “Advance Directive” is a general term that refers to your oral/written instructions about your future medical care, in the event that you become unable to speak for yourself. Each state regulates the use of the advance directive differently. There are two types of advance directives: a living will and a medical power of attorney. If you would like a copy of the Official AZ state advance directive forms, please visit www.azsos.gov/adv_dir/. Do you have an executed Advance Directive/Living Will? If yes please provide a copy to Pain and Wellness of Arizona. Yes No Do you have an executed Health Care Power of Attorney? If yes please provide a copy to Pain and Wellness of Arizona. Yes No Notice of Privacy Practice THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. At Pain & Wellness of Arizona, we are committed to treating and using your protected health information responsibly.This notice of Health Information Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 2003, and applies to all protected health information as defined by federal regulations. Understanding Your Health Record/Information Each time you are seen by Pain & Wellness of Arizona, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a: Basis for planning your care and treatment, Means of communication among the many health professionals who contribute to your care, Legal document describing the care you received, Means by which you or a third-party payer can verify that services billed were actually provided, A tool in educating heath professionals, A source of data for medical research, A source of information for public health officials charged with improving the health of this state and the nation, • A source of data for our planning and marketing, A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve, Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others Your Health Information Rights Although your health record is the physical property of Pain & Wellness of Arizona, the information belongs to you. You have the right to: Obtain a paper copy of this notice of information practices upon request, Inspect and copy your health record as provided for in 45 CFR 164.524, Amend your health record as provided in 45 CFR 164.528, Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528, Request communications of your health information by alternative means or at alternative locations, Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522, and Revoke your authorization to use or disclose health information except to the extent that action has already been taken. Examples of Disclosures for Treatment, Payment and Health Operations We will use your health information for treatment: For example: Information obtained by a nurse, physician, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the physician will know how you are responding to treatment. We will also provide your physician or a subsequent health care provider with copies of various reports that should assist him or her in treating you once you’re discharged from this hospital. We will use your health information for payment: For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. We will use your health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide. Business associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, billing services, and a copy service we may use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information. Directory: Unless you notify us that you object, we will use your name, location in the facility, general condition, and religious affiliation for directory purposes. This information may be provided to members of the clergy and, except for religious affiliation, to other people who ask for you by name. Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition. Communication with family: Health professionals, using their best judgement, may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. Funeral directors: We may disclose health information Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Pain & Wellness of Arizona, is required to: Maintain the privacy of your health information, Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you, Abide by the terms of this notice, Notify you if we are unable to agree to a requested restriction, and Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us, or if you agree, we will email the revised notice to you. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy Officer at 480-3604444, or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is:Office for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201 New Medical Patient Packet
