THE CENTER FOR HEADACHE, SPINE, AND PAIN MEDICINE Authorization for Exchange of Medical Information To Whom It May Concern, I, herby authorize The Center for Headache, Spine and Pain Medicine to receive any medical documents relevant to my condition and treatment. To Recipient: 1 2. 3. Signature: Date: Date of Birth: Thank you 415 N Crescent Dr. #140, Beverly Hills, CA 90210
THE CENTER FOR HEADACHE, SPINE, AND PAIN MEDICINE HIPAA PATIENT CONSENT FORM Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice also contains a patient rights section describing your patient rights under the law. You have a right to review this notice before signing the consent. The terms of the notice may change, and if this should occur, you may receive a revised copy by contacting the office. You have the right to restrict how protected health information about you is used or disclosed for treatment, payment, or healthcare operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, or healthcare operations. You have a right to revoke this consent in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in relation to you on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The patient understands that: 1) Protected health information may be disclosed or used for treatment, payment, or health care operations. 2) The practice has a Notice of Privacy Practices and the patient has the opportunity to review this notice. 3) The practice reserves the right to change the notice of privacy practices. 4) The patient has the right to request restricted use of their information, but the practice does not have to agree to those restrictions. 5) The patient may revoke this consent in writing at any time and all future disclosures will then cease. The Consent is signed by: Printed Name (Patient name or representative) Signature Date 415 N Crescent Dr. #140, Beverly Hills, CA 90210
THE CENTER FOR HEADACHE, SPINE, AND PAIN MEDICINE Informed Consent I,, give permission to Dr. Ezekiel Fink, to provide pain medication to me for my medical treatment I understand that Dr. Fink s role in me care will be that of a treating physician and consultant for pain related diagnosis. I further understand that Dr. Fink will not assume the role of my primary treating physician. My pain management treatment plan will be clarified at my early visits and I understand that this care may be time limited and that I may be referred back to my primary treating physician when my condition has stabilized. I understand the Dr. Fink will document the care provided and that these records are available to other professionals involved in my care. In this regard Dr. Fink will not be able to provide legal reports unless special arrangements are made upon my request and additional fees are paid where applicable. I have read and understand the above. Patient Signature Patient Name (please print) Date 415 N Crescent Dr, #140, Beverly Hills, CA 90210
THE CENTER FOR HEADACHE, SPINE, AND PAIN MEDICINE Email Correspondence Agreement I understand that email correspondence with the staff and healthcare providers at the Center for Headache, Spine and Pain Medicine is not for emergencies or issues that require immediate attention. If an issue arises that requires immediate attention arises, I will contact a healthcare provider by phone or seek immediate/emergent care. Patient Signature Date 415 N Crescent Dr. #140, Beverly Hills, CA 90210
THE CENTER FOR HEADACHE, SPINE, AND PAIN MEDICINE NARCOTIC USAGE CONTRACT Patient Name: This policy is enacted to ensure the safe and proper use of any controlled substances. Please Initial: 1. Patient will provide physician with a complete and accurate history including past medical records, past pain treatments and hospitalizations, drug and alcohol use and drug abuse and addiction history. 2. Patient agrees and gives permission for family members, significant others, roommates, healthcare professions and law enforcement officials to provide information for the purpose of obtaining information relevant to evaluating the efficacy, non-efficacy, side effects, or appropriateness of the medication prescribed. 3. Patients must be seen regularly in the clinic, and may be asked for a urine sample for drug screening without notice, any visit and at any time. 4. Patients must receive narcotic prescriptions from only this physician s office which are to be filled at only one pharmacy. 5. Patient will inform MD of all noticed drug side effects and any concerns about the medication 6. Patient will NOT take prescribed medication in ANY manner OTHER THAN as directed without first contacting the physician, as this would constitute reason for terminating the prescribing relationship. Furthermore, abuse of prescriptions will prompt notification of all pertinent area physicians and necessary legal authorities. 7. Lost or stolen drugs or prescriptions will not be accepted as a reason for refill prior to the appropriate time period. This office AND local law enforcement agencies must be Notified of such loss or theft. 1
NEUROLOGICAL PAIN INSTITUTE NARCOTIC USAGE CONTRACT Patient Name: Please Initial: 8. This mode of TREATMENT WILL BE STOPPED IF any ONE of the following occurs: Patient hoards, gives, sells or misuses these controlled drugs or any other illegal drug. Patient develops rapid tolerance or loss of effectiveness from this treatment. Patient develops side effects that are significant in the view of the physician. Patient s functional activities decrease. Patient obtains any form of opiates or narcotics from sources other than the physicians in this office. 9. Pregnancy may warrant discontinuance of opiate therapy at the discretion of the treating physician. 10. If narcotic abuse occurs, the drug will be stopped /tapered immediately, and the patient agrees to enter a detoxification program if requested. 11. Patient will not operate machinery or drive when feeling drowsy or when patient can expect to feel drowsy from medication, or at other times considered necessary at the discretion of the treating physician. 12. Patient understands that the physicians of the Neurological Pain Institute will be reasonable but firm in interpreting all of the above policy statements. 2
NEUROLOGICAL PAIN INSTITUTE NARCOTIC USAGE CONTRACT REGARDING DRIVING OR USE OF HAZARDOUS MACHINERY: Pain medicine (both narcotic and non-narcotic) can decrease your alertness and thereby make certain activities such as driving more dangerous. You should take great care to avoid injury to yourself or others while taking these medicines. As each person responds differently to these medicines it is impossible for your physician to know what is a safe dose for you to take while driving. Some patients will be able to drive safely once they become accustomed to their medicines, but others will not. As with the use of alcohol, you must exercise careful personal judgment to determine in which activities you may safely participate while taking your medicines. In some cases it will become apparent to the physician that driving is not safe. In these cases the physician will advise you against driving. If necessary your physician will notify the Dept. of Motor Vehicles that driving privileges should be restricted. THEREFORE, by my signature below, I affirm that I have read (or have had read to me) this Narcotic Usage Contract, understand it, and have had all questions answered satisfactorily, and thus, I (the patient) CONSENT TO THE USE OF OPIATES/NARCOTICS UNDER THE TERMS AS OUTLINED IN THIS AGREEMENT. Patient Signature: Witness Signature: Date: Date: 3
THE CENTER FOR HEADACHE, SPINE, AND PAIN MEDICINE Patient Information: Intake Form Name: Age: Date: Address: (complete mailing address) Phone No.: ( ) Date Of Birth: Soc. Sec. No.: Male Female * Right Handed Left Handed Both * Height: Weight: Attorney Information: Name: Phone No.: ( ) Address: Fax No.: ( ) HISTORY OF THE INJURY: Date of Injury: Please Describe How Your Injury Occurred: Please List The Injured Body Parts as a result of your accident: CHIEF COMPLAINTS: What are your current complaints? (for example: low back pain, headache etc.) 1. 2. 415 N Crescent Dr. #140, Beverly Hills, CA 90210
Patient Name Date 3. Where are your current symptoms? In The Last Two Months Has Your Condition? Stayed The Same Improved Worsened Fluctuated But Overall Has Stayed About The Same If Your Condition Has Worsened, Please Explain: 416 N. Bedford Dr. Suite 307, Beverly Hills, CA 90210 2
Patient Name Date If Your Condition Continues To Improve, Please Explain: HISTORY OF TREATMENT: When Did You First Seek Treatment For Your Injury? Date: Did Your Employer Send You For Treatment? YES NO Did You Seek Treatment On Your Own? YES NO INITIALLY, Did You Go To A Hospital/Emergency Room? YES NO Name Of Hospital/ER? City: Were You Admitted To The Hospital? How Long? Please list ALL Doctors You Have Seen Regarding Your Injury. Please List Them In The Order You Saw Them In. Name Of Doctor/Facility #1: City/Location: Type Of Doctor (degree or specialty): Describe Treatment And/Or Tests: What Did This Doctor Say Was Wrong With You? Did This Doctor Take You Off Work? Give Dates: Did This Doctor Restrict Or Modify Your Work Activities? How? Did This Doctor Refer You Anywhere Else? Where And Why? Name Of Doctor/Facility #2: City/Location: Type Of Doctor (degree or specialty): Describe Treatment And/Or Tests: What Did This Doctor Say Was Wrong With You? Did This Doctor Take You Off Work? Give Dates: Did This Doctor Restrict Or Modify Your Work Activities? How? Did This Doctor Refer You Anywhere Else? Where And Why? 416 N. Bedford Dr. Suite 307, Beverly Hills, CA 90210 3
Patient Name Date Name Of Doctor/Facility #3: City/Location: Type Of Doctor (degree or specialty): Describe Treatment And/Or Tests: What Did This Doctor Say Was Wrong With You? Did This Doctor Take You Off Work? Give Dates: Did This Doctor Restrict Or Modify Your Work Activities? How? Did This Doctor Refer You Anywhere Else? Where And Why? Name Of Doctor/Facility #4: City/Location: Type Of Doctor (degree or specialty): Describe Treatment And/Or Tests: What Did This Doctor Say Was Wrong With You? Did This Doctor Take You Off Work? Give Dates: Did This Doctor Restrict Or Modify Your Work Activities? How? Did This Doctor Refer You Anywhere Else? Where And Why? Name Of Doctor/Facility #5: City/Location: Type Of Doctor (degree or specialty): Describe Treatment And/Or Tests: What Did This Doctor Say Was Wrong With You? Did This Doctor Take You Off Work? Give Dates: Did This Doctor Restrict Or Modify Your Work Activities? How? Did This Doctor Refer You Anywhere Else? Where And Why? 416 N. Bedford Dr. Suite 307, Beverly Hills, CA 90210 4
Patient Name Date TYPES OF TREATMENT: Are You Currently Taking Medication To Relieve The Effects Of This Injury? Please Explain What You Take, (Prescription or Non-Prescription): Do any of these medications help? Have you had any injections done for treatment? please explain Have you had any surgery done for treatment? please explain Are You Currently Using A Brace, Support, Cane, Crutch(es), Wheelchair, TENS Unit, Or Other Aid Because Of The Effects Of This Injury? What Treatment(s) Offer You The Most Relief, And How Long Do The Benefits Last? Have There Been Any Recommendations For Diagnostic Testing Or Treatment That You Have Not Received? 416 N. Bedford Dr. Suite 307, Beverly Hills, CA 90210 5
Patient Name Date HISTORY OF OTHER INJURIES: Have You Ever Experienced The Same Or Similar Symptoms/Problems BEFORE This Injury? Please Explain: Have You Ever Had A PRIOR, Injury(ies)? Please Explain: Have You Ever Served In The Military? Have You Had Any NEW INJURIES Involving Body Parts Which Are A Part Of Your Current Injury? Please Explain: ACTIVITIES OF DAILY LIVING: Please Indicate Any Limitations, Difficulties Or Impairments You Have With Any Of The Activities listed below. 1. Self-Care, Personal Hygiene: (Example Urinating, Defecating, Brushing Teeth, Combing Hair, Bathing, Dressing Oneself, Eating) 2. Communication: (Example Writing, Typing, Seeing, Hearing, Speaking) 416 N. Bedford Dr. Suite 307, Beverly Hills, CA 90210 6
Patient Name Date 3. Physical Activity: (Example Standing, Sitting, Reclining, Walking, Climbing Stairs) 4._ Sensory Function: (Example Hearing, Seeing, Tactile Feeling, Tasting, Smelling) 5. Nonspecialized Hand Activities: (Example Grasping, Lifting, Tactile Discrimination) 6. Travel: (Example Riding, Driving, Flying) 7. Sexual Function: (Example Orgasm, Ejaculation, Lubrication, Erection) 8. Sleep: (Example Restful, Nocturnal Sleep Pattern) OTHER: What type of work are you doing now? What type of physical activity are you doing now? PAST MEDICAL HISTORY: Please List The Information About Your Medical History In The Sections Below, With The Approximate Dates. Childhood Illnesses: Adult Illnesses: 7 416 N. Bedford Dr. Suite 307, Beverly Hills, CA 90210
Patient Name Date Injuries (motor vehicle accidents, bone fractures etc): Allergies: Present Medications Taken (Prescription & Over-The-Counter): Surgeries: Hospitalizations: FAMILY HISTORY: List Any Health Problems In Your Immediate Family: (Mother, Father, Brother, Sister) SOCIAL HISTORY: Single Married Separated/Divorced Widowed Employed Unemployed Retired Employer: If you had an injury, was it work related? Yes No (if Yes, which employer: ) Disability: Yes No Litigation: Are you currently involved or planning on initiating a legal case? Yes No Tobacco: Yes-Currently Yes-in the past No-never How many packs/day? How many years did you smoke for? When did you quit? Alcohol: Yes No How many drinks/week? Illicit Drug Abuse: Marijuana Heroin Cocaine Amphetamines Other: Have you ever had a problem w/ prescription medications (ie: misuse, abuse, addiction)? Yes No Which drugs? History of Alcohol Abuse: Yes No How long have you been sober? History of Substance Abuse: Yes No How long have you been sober? REVIEW OF SYSTEMS: (please check the box if you have had any of these symptoms recently) Constitutional: Fever Unexpected Weight loss Unexpected Weight gain Fatigue Sweats Chills Head & Neck: Ringing in the ears Congestion Difficulty Swallowing Hearing Loss Glaucoma Blindness Blurry Vision Pulmonary: Shortness of breath Wheeze Cough Require Oxygen 416 N. Bedford Dr. Suite 307, Beverly Hills, CA 90210 8
Patient Name Date Cardiac: Chest Pain Palpitations Heart Attack Arrhythmia Valve disease High Blood Pressure Gastro-intestinal: Nausea Vomiting Heartburn Constipation Diarrhea Hemorrhoids Blood in stool Ulcers Genito-Urinary: Frequent urination Difficulty urinating Painful intercourse Menstrual problems Pain during urination Kidney Stones Prostate problems Blood in urine Skin: Easy Bruising Itching Rash Jaundice Musculoskeletal: Joint Pain Muscle Cramps Fractures Difficulty walking (requiring cane/walker) Hematologic/Endocrine Thyroid Problems Diabetes Bleeding gums Bleeding disorder Hair loss Psychological: Depression Anxiety Panic Attacks Suicide attempts Suicidal thoughts Emotional Problems Mood disorder Neurological: Headaches Seizures Paralysis Dizziness Memory Loss Confusion OFF WORK ACTIVITIES: Do You Exercise? Please Explain Do You Participate In Any Sports Activities? Please Explain : Do You Have Any Hobbies? Please Explain Are You Able To Perform Your Normal/Regular Household Chores/Activities? Please Explain: 416 N. Bedford Dr. Suite 307, Beverly Hills, CA 90210 9