INTERVENTIONAL SPINE & PAIN MANAGEMENT
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1 INTERVENTIONAL SPINE & PAIN MANAGEMENT PATIENT INFORMATION SHEET NAME: LAST FIRST MIDDLE INTIAL ADDRESS CITY STATE ZIP HOME PHONE ( - CELL PHONE ( - WORK PHONE ( - EXT PRIMARY CARE DOCTOR REFERRING PHYSICIAN DATE OF BIRTH / / SEX! F! M SOCIAL SECURITY / / MARITAL STATUS! SINGLE! DIVORCED! LEGALLY SEPARATED! PARTNER EMERGENCY CONTACT PHONE ( - EMPLOYER NAME ADDRESS EMPLOYMENT STATUS:! EMPLOYED! UNEMPLOYED! DISABILITY! RETIRED! PART TIME! SELF EMPLOYED RESPONSIBLE PARTY::! SELF! GUARANTOR RELATIONSHIP NAME ADDRESS CITY STATE ZIP DOB / / MEDICAL INSURANCE INFORMATION PRIMARY INSURANCE CARRIER ID# CLAIMS ADDRESS GROUP# POLICY HOLDER NAME DOB SEX SSN SECONDARY INSURANCE CARRIER ID# CLAIMS ADDRESS GROUP# POLICY HOLDER NAME DOB SEX SSN PLEASE SIGN BELOW: I AUTHORIZE KEERANKUMAR MD TO BILL TO MY INSURANCE CARRIER. I ATTEST THAT THE INFORMATION ABOVE IS TRUE AND CURRENT. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNTS NOT COVERED BY MY INSURANCE CARRIER AND AGREE TO PAY MY BALANCE IN A TIMELY MANNER. PATIENT, PLEASE SIGN FOR PERMISSION TO TREAT GAURDIAN, SIGN HERE FOR PERMISSION TO TREAT DATE
2 MEDICAL(QUESTIONNAIRE( PATIENT'SNAME: DATEOFBIRTH: HEIGHT WEIGHT DOMINANTHAND:RIGHT LEFT PAST MEDICAL HISTORY PAST SURGICAL HISTORY YES NO Year f Surgery DIABETES APPENDIX GALL BLADDER HEART ATTACK TONSILS HEART FAILURE TUBAL LIGATION CHEST PAIN HYSTERRECTOMY STROKE C SECTION ANEMIA KIDNEY SEIZURES BACK (SPECIFY ARTHRITIS NECK (SPECIFY OSTEOPOROSIS KNEE FREE/EASY BLEEDING HIP ULCERS HEART CATH REFLUX HEART BYPASS HEPATITIS OTHER (SPECIFY HIV/AIDS HIGH BLOOD PRESSURE EMPHYSEMA ALLERGIES (LIST REACTION ASTHMA ANXIETY DEPRESSION OTHER (SPECIFY REVIEW OF SYMPTOMS FEVER/CHILLS NAUSEA/VOMITING CONSTIPATION WEIGHT GAIN/LOSS TINGLING/NUMBNESS SEDATION WEAKNESS INSOMNIA SWEATING LEG CRAMPS WEAKNESS IN ARMS/LEGS SWELLING IN ARMS/LEGS SHORTNESS OF BREATH!LOW BLOOD SUGAR HIGH STRESS LEVELS EASILY FATIGUED!LOSS!OF!FEELING!IN!LEGS!!!!!!!!!!!!!!!!!!!!!!!!!!SLEEP!DISTURBANCES JOINT STIFFNESS!LOSS!OF!FEELING!ON!ONE!SIDE!!!!!!!!!!!!!!!!RECEIVING!COUNSELING HEADACHE!MUSCLE!STIFFNESS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!WHEEZING/COUGHING CHEST PAIN ITCHING OR RASH OTHER
3 MEDICATIONS:(PLEASELISTDOASGEANDHOWMANYPILLSPERDAY:LISTALLMEDICATIONSWITHOUT EXCEPTION DRUG DRUG DRUG DRUG DRUG DRUG **PLEASELISTANYBLOODTHINNERSYOUARE CURRENTLYTAKINGINCLUDINGASPIRIN,COUMADIN, WARFARIN,PLAVIX,EFFIENT,PLETAL,AGGRENOX, GOODY SPOWDER,LOVENOX,PRADAXA** VERYIMPORTANT!! DRUG DRUG IMAGING:(PLEASELISTANYRECENTMRI,XRAY,CTSCAN APPROXDATE SOCIAL(HISTORY:(( OCCUPATION: MARITALSTATUS: ALCOHOLUSE Y N SMOKE YES NO QUITYEAR RECREATIONALDRUGS Y N FAMILY(HISTORY:( HEARTATTACK Y N HEARTDISEASE Y N HIGHBLOODPRESSURE Y N DIABETES Y N CANCER Y N PREVIOUS(TREATMENT(S(((((((EFFECTIVE( Acupuncture!! Yes!! N! Chirpractr!! Yes!! N! Bifeedback!! Yes!! N! Tractin!!! Yes!! N! TENS!Unit!!! Yes!! N! Physical!Therapy!! Yes!! N! Massage!!! Yes!! N! Psychlgist!! Yes!! N! Psychiatrist!!! Yes!! N! Alternative!Medicine! Yes!! N! Surgery!!! Yes!! N! Medicatins!! Yes!! N! Epidurals!Sterids!! Yes!! N ANY!PARTICULAR!THERAPIES!YOU!ARE!INTERESTED!IN?!!! ANY!PARTICULAR!THERAPIES!YOU!PREFER!TO!AVOID?!!!!!
4 Interventinal Spine & Pain Management Keeran Kumar, M.D. 530 Lmas Santa Fe Dr, Suite B, Slana Beach, CA, Tel: Fax: AUTHORIZATION FOR RELEASING HEALTH INFORMATION Date: Patient Name: Scial Security N: Phne Number: Purpse r need fr infrmatin: I hereby authrize that Keeran Kumar, M.D. OBTAIN The prtected health infrmatin regarding the abve named persn t be used in treatment and diagnsis by Interventinal Spine and Pain Management. Persn/Institutin: Address: Phne: Fax: I understand that recrds are prtected under the Federal Cnfidentiality Regulatins and cannt be disclsed withut my written authrizatin unless therwise prvided fr in the regulatins. PROHIBITION OF DISCLOSURE: Alchl and drug abuse infrmatin, if present has been disclsed frm recrds whse cnfidentiality is prtected by federal law. Federal Regulatin (42 CFR Part 2 prhibits recipients frm making any further disclsure f this infrmatin except with specific written cnsent t the patient. DIV testing, ARC and/r AlDS related diagnsis is further prhibited frm disclsure by state Regulatins withut the specific written cnsent f the patient. A general authrizatin fr the release f infrmatin if held by anther Party is nt sufficient fr this purpse. RE-DISCLOSURE: Ntice is hereby given t the patient f legal representative signing this authrizatin that Keeran Kumar, M.D. cannt guarantee that the recipient receiving the requested health infrmatin will nt re-disclse it t thers. Ntice is hereby given t the recipient that law prhibits the re-disclsure f any health infrmatin regarding drug and r alchl abuse, DIV and mental health treatment. Signed: (Patient r Legal Guardian Witness:
5 NARCOTIC CONTRACT Keeran Kumar, M.D. understands that yur pain is a significant hindrance t the quality f life yu desire. In rder t help yu achieve yur gals we may utilize ral narctics r ther medicatins supplemented with the prcedures yu receive here. Narctics have a lng histry f safety when used in the prper manner Side effects can include, but nt limited t, cnstipatin, urinary retentin, itching, nausea, and smetimes cnfusin. Addictin t narctics may ccur with use ver several weeks; therefre, we must weigh the risks versus benefits befre using these medicatins. We will discuss these with yu when they are prescribed and yur pharmacist will als give yu mre infrmatin. It is imprtant t take all medicatins in the way that they are prescribed by yur physician. Taking mre medicatin then is prescribed fr yu can result in, but nt 1imited t, respiratry failure, cardiac arrhythmias, GI bleed and/r death. Please be certain t take yur medicatins as prescribed. Listed belw are the cnditins yu must adhere t in rder t be under the care f the Keeran Kumar, M.D.. If any f these rules are brken, we reserve the right t dismiss yu frm ur care: I agree t take my medicatin as prescribed. Ifpain level increases such that I need t increase my dsage, I will call and discuss this with a nurse r physician. If given narctic medicatins frm Keeran Kumar, M.D., I will receive these nly frm Keeran Kumar, M.D. fr the duratin f my care. I will take n ther pain medicatins until I speak with a nurse r Keeran Kumar, M.D. I agree t receive my prescriptins nly frm ne pharmacy, t be recrded in my medical chart. I will prtect my prescriptins and medicatins. Only ne lst prescriptin r medicatin will be replaced in a single year. After this, a plice reprt is needed and medicatin will be replaced/refilled at the physician's discretin. I will cnsent t randm drug testing. I will keep my scheduled appintments. If I need t cancel an appintment, 1will give 24 hurs ntice and will call t cancel r reschedule. All narctic medicatins must be refilled in persn by appintment in clinic. My medicatins will nt be refilled after ffice hurs, n weekends r hlidays. All ineffective medicatins MUST be returned and may nt be discarded in trash r flushed dwn tilet. I understand my pain medicatins may be stpped if ne f the fllwing ccurs: My physician feels that narctics are nt helping t relieve my pain My ability t functin has nt imprved I develp rapid tlerance t the treatment r the treatment fails t be effective I develp side effects that are f cncern t my physician I give, sell, r misuse the narctics I btain narctics frm any ther surces withut ntifying Keeran Kumar, M.D. (includes ER visits An imprtant part f my pain management plan may include nn-narctic treatment. If I d nt fllw thrugh with all aspects f my care (including nn-narctic meds, my narctic treatment may be re-evaluated r terminated. If I have questins r cncerns abut my pain management, I will call Keeran Kumar, M.D. at THIS CONTRACT WILL REMAIN IN EFFECT FOR THE DURATION OF MY CARE. I understand the abve infrmatin and agree t abide by this cntract: (Print Name (Signature Pharmacy name and number (t be recrded in chart at initial visit:
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