New Patient Paperwork

ID
Appointment Date
Calendar Resource
Appointment Type
Appointment Time
Location
Patient's Name
New Patient Paperwork- Pain Management

Thank you for choosing Southwest Spine and Pain, attached is the new patient paperwork. Please be aware this may take roughly 20-30 minutes to complete, and you will need the following information: insurance cards, referring provider's name and phone number, primary care provider's name and phone number, current medications, past procedures, surgeries, or treatments. You must click "SUBMIT" to complete your submission, failure to do so will result in a loss of the information you have entered. If you wish to save and complete later, you must click "SAVE" (do not just leave the window open), failure to do so will result in a loss of any information you have entered.
Please note: If you are unable to complete and submit the forms prior to your scheduled appointment, please arrive 30 minutes early to do so or we may need to reschedule. Thank you.
Patient Information:
Patient Name*

First NameLast Name
Date of Birth*
Preferred Language*
Sex*

MaleFemaleOther
SSN
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email Address*
example@example.com
Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

Please read and sign:
I, the undersigned, hereby consent to the following Treatment:
- Administration and performance of all treatments
- Administration of any needed anesthetics
- Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient
- Use of prescribed medication
- Performance of diagnostic procedures/tests and cultures
- Performance of other medically necessary or advisable based on the judgment of the attending physician or their assigned designees.
I fully understand that this is given in advance of any specific diagnosis or treatment.

I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing.

I understand that Southwest Spine and Pain Center may include consent at satellite offices under common ownership.

I, the undersigned, acknowledge that Southwest Spine and Pain Center will use and disclose my information for the purposes of treatment, payment, and healthcare operations as described in the Notice Privacy Practices.

A photocopy of this consent shall be considered as valid as the original.

I acknowledge that I am able to have access to a complete copy of the Southwest Spine and Pain Center “Notice of Privacy Practices”. I understand that if I have questions or complaints that I should contact the Privacy Official.

Medicare Patients: I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable services to Southwest Spine and Pain Center.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date
Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

Authorization to release or use information for treatment, payment, or healthcare options:
I herby authorize the release or use of my individually identifiable health information (protected health information or PHI) and medical information by Southwest Spine and Pain in order to carry out treatment, payment, or health care options. You should review the Practice's Notice of Privacy Practices for a more complete description of the potential release and use of such information, and you have the right to review such Notice prior to signing the Consent form. We reserve the right to change the terms of its Notice of Privacy Practices at any time. If we do make changes to the terms of its Notice of Privacy Practices, you may obtain a copy of the revised notice by writing our practice or requesting a copy from our front desk staff. You retain the right to request that we further restrict how your protected health information is released or used to carry out treatment, payment, or health care operations. Our practice is not required to agree to such requested restrictions; however, if we do agree to your requested restriction(s), such restrictions are then binding on the Practice.
I agree and consent to releasing information to me in the following manners:
via Primary Phone Number

Ok to leave detailed messageLeave call back number only
via Text Message

Ok to send detailed text messageOk to send electronic statement
via Email

Ok to send detailed messageDo not send detailed message
Permission to receive additional information or materials from Southwest Spine and Pain Center.

YesNo
Permission to release to the following individuals

(medical records, billing, payment, appointments, healthcare options)
Name of Individual:

First NameLast Name
Permission to release to external providers involved in my care

Ok to send records from Southwest Spine and Pain provider to external doctor involved in my care
By signing below, I attest that the information provided above is true and accurate.
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Signature*

Clear
Date:*

MonthDayYear
Date
Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

Answering the following screening “Health and Wellness Questionnaire” will help us understand your needs in multiple areas of your life and how we can best help you to be well. Participation is voluntary.*

Yes, I will participate.No, I wish not to participate.
Health and Wellness Questionnaire

At Southwest Spine and Pain Center, we believe in providing the best care possible. Answering the following questions will help us understand your needs in multiple areas of your life and how we can best help you to be well. Participation is voluntary. You are free to stop at any time, or to leave questions blank if you would prefer not to answer them. However, the more information we have, the better able we are to provide quality care.
1. In general, would you say your health is:
2. In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)
3. In general, how would you rate your physical health?
4. To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?
5. How would you rate your fatigue on average?
6. How would you rate your pain on average?
7. In general, would you say your quality of life is:
8. In general, how would you rate your mental health, including your mood and your ability to think?
9. How often have you been bothered by emotional problems such as feeling anxious, depressed, or irritable?
10. In general, how would you rate your satisfaction with your social activities and relationships?
11. In the past 7 days, my sleep quality was:
12. In general, would you say your nutrition is:
13. In general, would you say your fitness is:
Over the last 2 weeks, how often have you been bothered by any of the following problems?:
14. Feeling nervous, anxious or on edge.
15. Not being able to stop or control worrying.
16. Little interest or pleasure in doing things.
17. Feeling down, depressed, or hopeless.
Are past or present experiences with ABUSE impacting you in your life in a negative way?
Are past or present experiences with Violence (e.g., domestic, work, military) impacting you in your life in a negative way?
Are past or present experiences with Military or Combat impacting you in your life in a negative way?
Are past or present experiences with unexpected death of a family member or friend (i.e. suicide, accidents, etc) impacting you in your life in a negative way?
Health and Wellness Continued: Please answer these questions based on the last 12 months.

These questions refer to use of alcohol, illegal drugs, prescription drugs not prescribed to you, or misuse of your prescriptions. Do not check “yes” in reference to taking your prescription medications as prescribed by your doctor.
Have you felt you ought to cut down on your drinking or drug use?
Have people annoyed you by criticizing your drinking or drug use?
Have you felt bad or guilty about your drinking or drug use?
Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?
Only click "save" if you wish to save and continue later, otherwise click "Next" to continue completing the paperwork. Leaving the window up and returning without clicking save, may result in a loss of any information entered.

PLEASE CLICK SUBMIT

(If you have completed your paperwork, please click submit. If you wish to save and continue later, please click save. Keeping your window open without saving or submitting will result in a loss of all entered information.)
Should be Empty:

	Date the Imaging was done:	Location the Imaging was done: (City/State)	Name of the Facility where Imaging was done:
X-ray
MRI
CT Scan
EMG
Bone Scan

	Relief	Duration	Name of Doctor	Name of Facility	Date of Procedure	Level of procedure: (Ex- L5-S1)
Radiofrequency Ablation
Facet Injection
Epidural Injection
Kyphoplasty
SI Joint Injection
Hip Injection

	What type of surgery was performed in this spine region?	Levels of Surgery: (if known. Ex: L5-S1)	Date of the Surgery:	Name of the Surgeon who performed the surgery (if unsure, type "unknown"):	Name of the Facility where surgery was performed:
Cervicothoracic Spine Surgery
Lumbosacral Spine Surgery
Scoliosis Surgery

	What type of surgery was performed in this spine region?	Levels of Surgery: (if known. Ex: L5-S1)	Date of the Surgery:	Name of the Surgeon who performed the surgery (if unsure, type "unknown"):	Relief of Surgery (0-100% relief how much did it help? 100% = cured the issue)	Duration of relief from the Surgery (Ex: * days, * months, * years)
Cervicothoracic Spine Surgery #2
Lumbosacral Spine Surgery #2
Scoliosis Surgery #2
Unknown Type Spine Surgery #2

	What type of surgery was performed in this spine region?	Levels of Surgery: (if known. Ex: L5-S1)	Date of the Surgery:	Name of the Surgeon who performed the surgery (if unsure, type "unknown"):	Relief of Surgery (0-100% relief how much did it help? 100% = cured the issue)	Duration of relief from the Surgery (Ex: * days, * months, * years)
Cervicothoracic Spine Surgery #3
Lumbosacral Spine Surgery #3
Scoliosis Surgery #3
Unknown Type Spine Surgery #3

New Patient Paperwork- Pain Management

Patient Information:

Emergency Contact

Insurance Information

Insurance Information

Referring Provider

Primary Care Provider

Please read and sign:

Authorization to release or use information for treatment, payment, or healthcare options:

I agree and consent to releasing information to me in the following manners:

Permission to release to the following individuals

FINANCIAL AGREEMENT

Location of Pain

Accident/ Injury

Allergies

Medications

Past Medical History

Social History

Surgical History

Health and Wellness Questionnaire

Over the last 2 weeks, how often have you been bothered by any of the following problems?:

Health and Wellness Continued: Please answer these questions based on the last 12 months.

	Yes	No
Have you had a fall in the last year?
Do you feel unsteady when walking or standing?
Do you have trouble remembering, learning new things, concentrating or making decisions?
Do you get lightheaded or dizzy from lying to standing?
Are there any safety hazards in your home like throw rugs or slippery floors?
Do you need support when getting in and out of the tub or up from the toilet?

	1	2	3	4	5	6	7	8+
Beer
Wine
Hard Liquor

	Never Used	Former User	Current SOME day User	1-9 daily (light)	10+ daily (heavy)
Cigarettes
Cigars
Pipe
Chewing Tobacco
Dipping Tobacco
Vape Pen