Medica Record #: Heath History Name: Phone: Date: DOB: Height Weight Mae Femae Updated: Pregnant Yes No Unknown* PAST MEDICAL HISTORY: Pease check beow if you have, or have had, any of these medica conditions: Primary Care Physician/Phone Number: NO PAST MEDICAL PROBLEMS Denta disease Acid refux Depression Adverse reaction to anesthesia Diabetes* Type of reaction: Down Syndrome* Azheimer s or significant memory oss Emphysema/COPD* Anemia Epiepsy/Seizures* Angina or chest pain* Esophagea Varices* Asthma* Fibromyagia Atria fibriation* Gout Badder probems Heart Attack* Beeding ucers Hemophiia/Beeding disorder* Bood cot* Hepatitis* Legs Lungs High bood pressure/hypertension* Cancer type: * High choestero Chemotherapy Yes No* HIV or AIDS Cirrhosis* Home Oxygen Liters/minute* Congestive heart faiure* Infections: Coronary artery disease* MRSA? Yes No Cystic Fibrosis* Irreguar heartbeat SURGICAL HISTORY: Pease check beow if you have had any of these surgeries: Kidney disease* Diaysis* Liver faiure* Maignant Hyperthermia* Muscuar Dystrophy* Osteoarthritis Osteoporosis Pneumonia Psychiatric disorder Rheumatoid arthritis Sicke ce* Seep apnea* CPAP machine Stroke (CVA)* Thyroid disease TIA* Other not isted, expain: NO PREVIOUS SURGERY Abdomina Cardiovascuar Heart Orthopaedic Appendectomy Coronary Bypass (CABG)* Cervica Spine Surgery Choecystectomy/Ga Badder Heart Vave Repacement* Lumbar Spine Surgery Coon Surgery Pacemaker/Defibriator* Upper Extremity Gastric Bypass Angiopasty/Stents* Hysterectomy Transpant* Lower Extremity Other Heart* Lung* Other Vascuar Other Aneurysm* ENT Carotid Surgery* Denta Artery Bypass Stents Arm or Leg* Breast Surgery REV 11/16/15 Prostate Surgery Other Continued
NAME DOB Date of Visit: Medica Record #: LIST ALL KNOWN ALLERGIES TO MEDICATIONS: NO MEDICATION ALLERGIES 1. Reaction type: 2. Reaction type: 3. Reaction type: Are you aergic to atex? Yes No If so what is the reaction? Tape aergy? Yes No Are you aergic or sensitive to metas/nicke? Yes No CURRENT MEDICATIONS: Incude herba and over-the-counter drugs. List a medications with dosage. Use additiona sheet if needed. NOT CURRENTLY TAKING MEDICATION 5: 1. 6: 2. 7: 3. 8: 4. 9: FAMILY HISTORY: Pease check beow if any of your immediate reatives have had any of the foowing and ist who: NO FAMILY MEDICAL HISTORY TO REPORT Adopted Yes No Cancer Reation: Hypertension Reation: Rheumatoid arthritis Reation: Adverse reaction to anesthesia Depression Maignant Hyperthermia* Stroke Reation: Beeding disorders Reation: B ood cots/pumonary emboism Reation: Reation: Diabetes Reation: Heart disease Reation: Reation: Osteoarthritis Reation: Osteoporosis Reation: Reation: Other not isted, expain: SOCIAL HISTORY: Marita status: Singe Married Partner Divorced Widow/Widower Hobbies Have you served in the armed forces? Y N Smoking: Never smoked Former smoker Current smoker How many packs/day? Do you dip or chew tobacco? Y N If Yes, how much per day? Do you drink acohoic beverages? Y N If Yes, how many drinks per week? Do you use recreationa drugs? Y N If Yes, what and how often? REVIEW OF SYSTEMS: Pease check beow if you have, or recenty experienced, any of these medica conditions: NO SYMPTOMS TO REPORT Fever/Chis/Night sweats: Y N Seizures* Y N Abdomina pain: Y N Fatigue: Y N Shortness of breath* Y N Anxiety: Y N Gynecoogica probems: Y N Skin wounds/rashes: Y N Arm/Leg pain: Y N Impotence: Y N Swoen gands: Y N Back, tarry stoos: Y N Incontinence: Y N Urinating at night: Y N Chest pain* Y N Irreguar heart rate* Y N Vascuar probems: Y N Denta probems: Y N Leg sweing: Y N Vision probems: Y N Depression: Y N Papitations* Y N Weight gain: Y N Easy beeding/bruising: Y N Psychoogica probems: Y N Amount: Weight oss: Y N Amount: REV 11/16/15
- Continued Date of injury/accident/onset of probem COMPLAINT/PROBLEM TODAY:
Consent to Treatment and Other Acknowedgments By reading and signing this document, I, the undersigned patient (or authorized representative) consent to and authorize the performance of any treatments, examinations, medications, anesthesia, medica services, and surgica or diagnostic procedures (incuding but not imited to the use of ab and radiographic studies) as ordered or approved by my attending physician(s), or any heathcare professiona assigned to my care by my attending physician(s), and I acknowedge and consent to the foowing: PROCEDURES: During the course of my care and treatment, I understand that various types of examinations, tests, diagnostic or treatment procedures ( procedures ) may be necessary. These procedures may be performed by physician(s), nurses, technicians, physician assistants, or other heathcare professionas. Whie routiney performed without incident, there may be materia risks associated with these procedures. If I have any questions concerning these procedures, I wi ask my physician(s) to provide me with additiona information. I aso understand my physician may ask me to sign additiona Informed Consent documents reating to specific procedures. NO GUARANTEE OF RESULTS: Resurgens physicians and heathcare professionas cannot guarantee any specific resut(s) of any examination, treatment, procedure or medica care. I reease Resurgens, its physicians and heathcare professionas from any iabiity for any accident or injury that is not directy caused by the negigence of Resurgens or its empoyees. PROVIDING ACCURATE INFORMATION: I understand that the heathcare professionas invoved in my care wi rey on my documented medica history, as we as other information provided by me, my immediate famiy, or others having information about me, in determining whether to perform or recommend procedures. I agree to provide accurate and thorough information regarding my medica history and any conditions or events which may impact medica decision-making. INDEPENDENT CONTRACTORS: Resurgens may utiize independent contractors for office, outpatient or inpatient treatment/procedures. These incude, but are not imited to, surgica assistants, physica therapists, and consuting and referra physicians. Heathcare professionas that are independent contractors are not agents or empoyees of Resurgens and are responsibe for their own actions. I understand that Resurgens sha not be iabe for the acts or omissions of independent contractors. This Consent to Treatment aso appies to any independent contractor utiized by my physician(s). AUTHORIZATION FOR RELEASE OF INFORMATION AND ASSIGNMENT OF THIRD PARTY PAYMENTS: I hereby expressy authorize Resurgens and a heathcare professionas providing care to reease a necessary information to any insurance company, heath pan or other entity (third party payor) which may be responsibe for paying for my care. I authorize and direct a payors to pay a benefits due for such care directy to Resurgens and a professionas (incuding independent contractors) providing for such care, and I hereby assign such sums to them. I understand this authorization and assignment sha remain vaid uness I provide written notice of revocation to Resurgens and the third party payor signed and dated by me; however, such revocation sha not be effective as to information reeased and/or charges incurred prior to such revocation. PAYMENT FOR SERVICES: In return for services to be provided by Resurgens, I promise to pay for services rendered by Resurgens to me or for my benefit. If the services I receive from Resurgens are covered by a third party payor, Resurgens may eect to bi and accept payment from such third party. I wi pay the portion of these bis which the third party payor determines are my responsibiity. In the case of services which I agree to receive but which are not covered by the third party, I wi pay the amount due upon receipt of services. I acknowedge that Resurgens wi attempt to obtain or confirm benefits and coverage information from my insurance company or other third party payer, but that this is not a guarantee of coverage or payment, nor does it reease me from any payment obigation for the services that I receive. If no third party is invoved in paying for my services, I agree to pay in fu for such services at the time the services are received. AUTHORIZATION AND RELEASE FOR PHOTOGRAPHS: I authorize and reease Resurgens and its empoyees and agents to take photographs, videos, x-rays, and/or other photographic, eectronic or other images of me and to use them as may be medicay appropriate. Such images may be used for educationa or other purposes as necessary and appropriate. These images may be maintained as a permanent part of my medica record. I understand and acknowedge that Resurgens may use cameras for security and patient monitoring, and patient confidentiaity wi be maintained for a such images. However we do not aow videotaping, recording or photography in the office without the physician s permission. VALUABLES: Resurgens assumes no responsibiity for, and I hereby reease Resurgens from iabiity for, oss or damage to any of my persona property whie on the premises and/or receiving treatment. By signing this document, I certify that I have read and understand its contents and that information provided by me is accurate and compete (incuding insurance information and current eigibiity for benefits). Patient/Parent/Guardian/Authorized Representative Date: If not signed by the patient, pease indicate reationship to the patient on the ine beow: A copy of this document may be utiized the same as the origina. Revision Juy 2014
PRIVACY NOTICE ACKNOWLEDGEMENT I acknowedge that the Resurgens Privacy Notice Revision Date, August 5, 2013 has been made avaiabe to me. A paper copy of this Notice wi be provided at my request. This Notice is aso dispayed in the waiting room and on the Resurgens website www.resurgens.com. Initias: MRN: Authorization to Reease Protected Heath Information I,, hereby authorized Resurgens Orthopaedics to reease my protected heath information to the foowing: (Pease check and provide the NAME or specific entities to who your protected heath information may be given.) Famiy members or friends: (pease give names) Schoo or Empoyer: (ist names of schoo/coach/empoyer) Other: Initias: This authorization sha be in effect (pease check one). no expiration date expiration date of Patient or Persona Representative s Name Printed X Patient or Persona Representative s Signature Date Office Use - Documentation of Good Faith Effort The patient identified above was made aware of the avaiabiity of the Privacy Notice on this date. A good faith effort has been to obtain a written acknowedgement of this. However, acknowedgement has not been obtained because: Patient refused to sign the Privacy Notice Acknowedgement Patient was unabe because: There was a medica emergency. Provider wi attempt to obtain acknowedgement as soon as practica Other reason, describe: Resurgens Empoyee Printed Name and Signature Privacy Notice Acknowedgement Rev.20150818
NARCOTIC CONTRACT AND PRESCRIPTION REFILL POLICY 1. I agree to aow 48 hours for prescription refis. 2. I understand that prescription refis requested after 4:00 pm wi not be received unti the next business day. 3. I understand that a foow-up visit may be required from my physician in order to obtain a refi. 4. I agree to take a medication exacty as instructed. I am NOT aowed to change the dosage amounts or ater the time schedue of taking the medication without first speaking to my physician. 5. I understand that narcotics and non-narcotic medications wi NOT be phoned in after hours or on the weekends. 6. Patients may be terminated from the practice with 30 days notice for noncompiance in the taking of their medications. In order to ensure compiance, Resurgens reserves the right to perform random drug screen monitoring on patients who require prescription narcotic medications over an extended period of time, as required by aw. Refusa to cooperate with a drug screen ikewise wi constitute a basis for termination from the practice. I certify that I wi vountariy provide a fresh and unaduterated saiva or urine specimen for testing. 7. Resurgens wi NOT refi prescriptions that have been ost or mispaced. 8. I must keep a appointments as recommended. 9. I wi not give, trade, or se medications. 10. The foowing are specific (but not excusive) grounds for immediate termination from the practice: 1) Obtaining narcotics from any other physician whie under Resurgens care. 2) Atering or forging of a prescription. This is a feony and wi be reported. 11. I am aware that most of the manufacturers of drugs used to treat chronic pain recommend against the operation of heavy equipment, which incudes driving a motor vehice. I am aware that if I choose to drive a vehice I coud be charged with a DUI. 12. I wi not combine any narcotic medications with the consumption of acoho. 13. I understand that ony one pharmacy may be used for fiing my prescriptions. My pharmacy s name and ocation is: (Pease notify us if you change pharmacies.) Pharmacy s Phone Number: I have read, understand and agree to the poicies above. I understand that if I do not sign this document, my physician may refuse to prescribe narcotic medications to treat my pain. I acknowedge having been provided a document entited Controed Substance Agreement and Informed Consent Form, and that I have a right to a paper copy upon request or can obtain a copy on the Resurgens website at http://www.resurgens.com, and I have had the opportunity to ask questions and receive answers to my satisfaction. Patient Name (Pease Print): Patient Signature: Date: Board Approved 5/14/14 -- Effective 5/14/14 FRMPAINMEDRX Revised 5/14/14
Controed Substance Agreement and Informed Consent Form In May of 2011 Governor Nathan Dea signed into aw SB 36, the Patient Safety Act of 2011, making Georgia one of the ast states in the nation to provide egisation for the impementation of a prescription drug monitoring program (PDMP) to combat the growing probem of prescription drug abuse. As a resut of this egisation and in the interest of promoting patient safety, the Georgia Composite Medica Board issued updated pain management minimum standards of practice (Rue 360.3.06) which require physicians to monitor patients to avoid narcotic dependency and addiction. A vioation of these rues coud subject the physician to sanctions and, more importanty, put patients at risk. The goa is to educate patients about the risks of ong term narcotic use and reduce prescription drug abuse. During the course of your treatment, your doctor may recommend the use of controed substances to treat your orthopaedic probem pre and post operativey. The purpose of this document is to make you aware of the risks, benefits and aternatives of taking controed substance medications in the treatment of pain and that there are federa and state aws reguating the prescribing of controed substances which require your physician to cosey monitor patients who receive these medications to avoid injury as a resut of misuse, abuse, toerance, dependency or addiction. You wi be asked to sign the Resurgens Narcotic Contract and Prescription Refi Poicy which sets out the terms and conditions required to receive controed substance medications and the consequences of noncompiance. This discosure is not meant to scare or aarm you, but rather it is an effort to make you better informed and of our commitment to ensure that your pain is managed in a safe and effective manner. I hereby consent to being prescribed controed substance(s), or narcotic medication(s) as an eement in the treatment of my pain. I further understand that these medication(s) are addictive and may, ike other drugs used in the practice of medicine, produce adverse affects or resuts. The aternative methods of treatment, the possibe risks invoved, and the possibiities of compications have been expained to me as isted beow. I understand that this isting is not compete, and that it ony describes the most common side effects or reactions, and that death is aso a possibiity as a resut from taking these medication(s). Benefits: When taken as directed by my physician, narcotic medications can be used safey and wi decrease pain, improve function and quaity of ife. Risks: The most common side effects and compications are constipation, nausea, vomiting, excessive drowsiness, itching, urinary retention, insomnia, depression, impairment of reasoning and judgment, respiratory depression, impotence, toerance to medication(s), physica and emotiona dependence, addiction and death. Aternatives: Continue with conservative treatment and non-narcotic pain medications. I understand that my physician may obtain medica records from prior treating physicians and a medication profie from my pharmacy to monitor my compiance and I agree to make other medica providers aware of my use of controed substances since use of other drugs may cause me harm. I understand that it may be dangerous for me to operate an automobie or other machinery whie using these medications and I may be impaired during a activities, incuding work. I must keep a reguar foow up appointments as recommended by my physician and that faiure to compy may cause discontinuation of narcotic prescription(s). I acknowedge understanding of the information contained herein by signing the Resurgens Narcotic Contract and Prescription Refi Poicy and understand that my physician wi answer any additiona questions I may have. With fu knowedge of the potentia benefits, possibe risks and aternatives invoved, I agree to the use of controed substances if prescribed and agree to compy with the terms and conditions of the Resurgens Narcotic Contract and Prescription Refi Poicy. Created 4/11/2012 Revised 10/9/12
Patient Name MRN Pease seect one of the foowing: Internet Googe Search Onine Advertising Facebook Emai Website Other: Biboard Gym Radio Station Newspaper/Magazine Friend or Famiy: Primary Care Physician: Other Physician: Sef (You ve known Resurgens for years!) ER Urgent Care Empoyer Insurance Company Yeow Pages Heath Fair Event Attorney TV Commercia Why do we need your e-mai address? To invite you to join our patient porta. The invitation wi come from Foow My Heath. Once you join, it wi enabe you to access your test resuts, receive summaries of your visit, communicate securey with your doctor and cinica team regarding your treatment, and pay your bi on-ine. To send you heath questionnaires to hep your doctor better monitor your progress and ensure that your treatment goas are met. To send you a survey asking for your opinions to hep us improve our services. My E-mai address I do not have e-mai I do not wish to share my e-mai address Signature Date Revised 12/14/15