New Patient Paperwork | Victory Pain Center

LAST NAME:

FIRST NAME:

ADDRESS:

Address Line 1

City

State

Zip Code

DATE OF BIRTH:

SS #:

HOME PHONE:

WORK PHONE:

CELL:

SEX:

M
F
Other

REFERRAL Dr:

PHONE: FAX:

EMAIL:

RELATION TO INSURED:

SELF
SPOUSE
PARENT
OTHER

INS COMP. / W/C:

BILLING ADDRESS:

PHONE:

FAX:

MEMBER ID:

GROUP:

CASE MANAGER:

PHONE:

FAX:

C/M EMAIL:

Divisor

ADJUSTER:

PHONE:

FAX:

ADJ EMAIL:

Divisor

DATE OF ACCIDENTE:

CLAIM #:

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NAME OF ATTORNEY:

PHONE:

FAX:

REGISTRATION

Patient Name and Last Name:

Responsible Party (If a Minor):

Phone:

Address:

Patient Employed By:

Business Address:

Occupation:

Business Phone:

SPOUSE (OR RESPONSIBLE PARTY) EMPLOYED BY:

Business Address:

Occupation:

Business Phone:

Purpose of Visit:

Who is responsible for this account?

Relationship to Patient:

Social Security #:

Do you have Medical Insurance?

No
Yes If Yes,

Name of Primary Insurer:

ID:

GROUP:

Name of Secondary Insurer:

ID:

GROUP:

I prefer to:

Pay my balance in full at time of service.
Pay my balance in full upon receipt to first statement.
Make payment arrangements prior to services being rendered.

In case of emergency, who should be notified?

Phone:

Your Drugstore Name:

Phone:

How did you learn of our practice?

ASSIGNMENT OF INSURANCE BENEFITS

The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependents, and that I will be bound by this signature as though the undersigned had personally signed the particular claim

I,

(NAME OF INSURED)

nereby authorized

(NAME OF INSURANCE COMPANY)

to pay and hereby assign directly to Howard W. Popp M.D., M.S., M.B.A all benefits, if any, otherwise payable to me for his/her services as descrited on the attached forms. I understand I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by and pay Howard W. Popp M.D., M.S., M.B.A will be credited to my account, in accordance with the above assignment.

(AUTHORIZED SIGNATURE )

DATE

HEALTH HISTORY

NAME:

DOB:

Today’s Date:

What is your reason for visit?

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SYMPTOMS: CHECK SYMPTOMS YOU CURRENTLY HAVE OR HAVE HAD IN THE PAST YEAR

GENERAL

CARDIOVASCULAR

MUSCLE/JOINT/BONE PAIN, WEAKNESS, MUMBNESS IN:

Choose

Arm
R
L

Checkboxes

Back
U
L

Checkboxes

Hand
R
L

Checkboxes

Hip
R
L

Leg

Leg
R
L

Neck

Neck
R
L

Shoulder

Shoulder
R
L

Feet

Feet
R
L

SKIN

WOMEN ONLY

Date of last menstrual period

Have you had a mammogram?

Are you pregnant?

Number of children

GASTROINTESTINAL

Bowel changes type

GENITO-URINARY

Blood in urine
Frequent urination
Lack of bladder control
Painful urination

EYE,EAR, NOSE, THROAT

MEN ONLY

Other

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CONDITIONS: CHECK CONDITIONS YOU HAVE OR HAVE HAD IN THE PAST

Checkboxes

Cancer Type

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ALLERGIES: TO MEDICATIONS, SUBSTANCE OR FOOD

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FAMILY HISTORY

FATHER - AGE

FATHER - STATE OF HEALTH

FATHER - AGE AT DEATH

FATHER - CAUSE OF DEATH

MOTHER - AGE

MOTHER - STATE OF HEALTH

MOTHER - AGE AT DEATH

MOTHER - CAUSE OF DEATH

Brothers

BROTHER - AGE

BROTHER - STATE OF HEALTH

BROTHER - AGE AT DEATH

BROTHER - CAUSE OF DEATH

Sisters

SISTER - AGE

SISTER - STATE OF HEALTH

SISTER - AGE AT DEATH

SISTER - CAUSE OF DEATH

Have you ever had a blood transfusion?

YES
NO

If yes, please give approximate date

Repeater

SERIOUS ILLNESS / INJURIES

DATE

OUTCOME

OCCUPATIONAL CONCERNS

CHECK IF YOUR WORK EXPOSES YOU TO THE FOLLOWING:

Stress
Hazardous Substances
Heavy Lifting
Other

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions that I may have made in the completion of this forms.

Patient Signature

Date

PERSONAL MEDICATION LIST

Patient Name and Last Name:

D.O.B:

Repeater

Prescription Medications

Dose

Time (s) of the day

Repeater

Over The Counter Medications

Dose

Time (s) of the day

Your Pharmacy Name, Address and Phone #:

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ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided a copy of the Notice of Privacy Practices (pages 1-4) and that I have read (or had the opportunity to read if I so chose) and understood the Notice.

Patient Name (please print)

Date

Parent or Authorized Representative (If applicable)

Signature

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Internal Use Only;

If the patient or patient’s representative refuses to sign acknowledgement of receipt of notice, please document the date and time the notice was presented to patient and sign below.

Presented on (date and time):

Date

Time

By (name and title):

Privacy Officer’s acknowledgement:

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OPIOID RISK TOOL (ORT)

Name:

Date:

Mark each box that applies

1.- Family History of substance abuse

2.- Personal History of substance abuse

4.- History of preadolescent sexual abuse

History of preadolescent sexual abuse

Female
Male

3.- Age (mark box if 16-45 years)

Age (mark box if 16-45 years)

Female
Male

5.- Psychological disease

Signature of Patient

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CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS

The Patient hereby consents to the use or disclosure of his/her individually identifiable health information ("protected health information") and patient medical record information by Victory Pain Center, Howard W. Popp. M.D., P.A. (the "Practice") in order to carry out treatment, payment, or health care operations. The Patient should review the Practice's Notice of Privacy Practices for a more complete description of the potential uses and disclosures of such information, and the Patient has the right to review such Notice prior to signing this Consent Form.

The Practice reserves for itself the right to change the terms of its Notice of Privacy Practices at any time. If the Practice does change the terms of its Notice of Privacy Practices, Patient may obtain a copy of the revised Notice.

Patient retains the right to request that the Practice further restrict how his/her protected health information is used or disclosed to carry out treatment, payment, or health care operations. The Practice is not required to agree to such requested restrictions; however, if the Practice does agree to Patient's requested restriction(s), such restrictions are then binding on the Practice.

Patient acknowledges and agrees that the Practice may disclose Patient's protected health information and patient medical record information to the following individuals who are either the Patient's family members, legal representatives, guardians, health care surrogates, or have power of attorney on behalf of the Patient:

CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS

Patient agrees that the Practice may disclose the following types of information contained in the Patient's medical records if Patient has NOT initialed the appropriate categories listed below:

HIV/AIDS Information
Mental Health Information
Substance Abuse Information
Sexually Transmitted Disease Information
If Patient is under the age of eighteen (18), Pregnancy Information

Patient agrees and consents to the Practice releasing information to Patient in the following alternative manners (please initial the appropriate spaces below):

Via e-mail to the Patient's designated e-mail address.
Via Regular Mail with any envelopes being marked personal and confidential and addressed to Patient.
The Patient may contact the Practice and provides the appropriate information (including the Patient's name, date of birth and/or social security number and unique personal identifier).

Patient's designated e-mail address

At all times, Patient retains the right to revoke this Consent. Such revocation must be submitted to the Practice in writing. The revocation shall be effective except to the extent that the Practice has already taken action in reliance on the Consent. The Practice may refuse to treat Patient if he/she (or an authorized representative) does not sign this Consent Form. If patient (or authorized representative) signs this Consent and then revokes it, the Practice has the right to refuse to provide further treatment to Patient as of the time of revocation (except to the extent that the Practice is required by law to treat individuals).

I HAVE READ AND UNDERSTAND THE INFORMATION IN THIS CONSENT. I IIAVE RECEIVED A COPY OF THIS CONSENT, AND I AM THE PATIENT OR AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS SEALED DOCUMENT VERIFYING CONSENT T0 THE ABOVE STATED TERMS.

Date / Time

Date

Time

Signature of Patient (or Authorized Representative*)

MEDICATIONS, Authority Name

Please Print Name

*Please explain Representative’s Relationship to Patient and include a description of Representative’s Authority to act on behalf of the Patient:

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BRIEF PAIN INVENTORY

Name:

Date:

1.-Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these everyday kinds of pain today?

1. Yes
2. No

2.- On the diagram, select where you feel pain.

Right Front Left
Left Back Right

Describe the areas where you feel pain on the front side of your body.

Describe area that hurts the most.

Describe the areas where you feel pain on the back side of your body.

Describe area that hurts the most.

3.- Please rate your pain by circling the one number that best describes your pain at its worst in the last 24 hours.

4.- Please rate your pain by circling the one number that best describes your pain at its least in the last 24 hours.

5.- Please rate you pain by circling the one number that best describes your pain on the average.

6.- Please rate your pain by circling the one number that tells how much pain you have right now.

7.- What treatment or medications are you receiving for your pain?

8.- In the last 24 hours. How much relief have pain treatments or medications provided? Please circle the one percentage that most shows how much relief you have received.

9.- Circle the one number that describes how, during the past 24 hours, pain has interfered with your:

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STRATFORD DISABILITY PAIN SCALE

PATIENT NAME:

DATE:

ACTIVITIES

TOTAL: EXTREME DIFFICULT Y OR UNABLE TO PERFORM ACTIVITY

TOTAL: QUITE A BIT OF DIFFICULTY

TOTAL: MODERATE DIFFICULTY

TOTAL: A LITTLE BIT OF DIFFICULTY

TOTAL: NO DIFFICULTY

SCORE:

Divisor

Divisor

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REGISTRATION

ASSIGNMENT OF INSURANCE BENEFITS

HEALTH HISTORY

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MUSCLE/JOINT/BONE PAIN, WEAKNESS, MUMBNESS IN:

WOMEN ONLY

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CONDITIONS: CHECK CONDITIONS YOU HAVE OR HAVE HAD IN THE PAST

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ALLERGIES: TO MEDICATIONS, SUBSTANCE OR FOOD

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FAMILY HISTORY

Brothers

Sisters

Repeater

OCCUPATIONAL CONCERNS

PERSONAL MEDICATION LIST

Repeater

Repeater

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ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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Internal Use Only;

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OPIOID RISK TOOL (ORT)

Mark each box that applies

1.- Family History of substance abuse

2.- Personal History of substance abuse

4.- History of preadolescent sexual abuse

3.- Age (mark box if 16-45 years)

5.- Psychological disease

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CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS

I HAVE READ AND UNDERSTAND THE INFORMATION IN THIS CONSENT. I IIAVE RECEIVED A COPY OF THIS CONSENT, AND I AM THE PATIENT OR AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS SEALED DOCUMENT VERIFYING CONSENT T0 THE ABOVE STATED TERMS.

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BRIEF PAIN INVENTORY

9.- Circle the one number that describes how, during the past 24 hours, pain has interfered with your:

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STRATFORD DISABILITY PAIN SCALE

ACTIVITIES

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