Medical Intake Form

WESTPORT PLAZA PAIN MANAGEMENT

MEDICAL INTAKE FORM

Date:______Last Name:______First Name:______MI:______

Address:______City, State,Zip:______

Employer:______Home Phone:______E-Mail:______

Date of Birth:______Age:______Please Circle: Male or Female

Social Security Number:______

Family Physician:______Phone:______Fax:______

If you do not have a primary care doctor at this time, you are required to find one within 30 days and provide us with their contact information so that we may coordinate care.

Please list medical concerns in order of importance (chief complaint #1):

1)______

2)______

3)______

4)______

Medical History: Please check all that apply

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Arthritis

Allergies (Hay fever)

Asthma

Alcoholism

Blood Pressure

Bronchitis

Cancer

Chronic Fatigue Syndrome

Carpal Tunnel Syndrome

Cholesterol-Elevated

Circulatory Problems

Colitis

Dental Problems

Depression

Diabetes

Diverticular Disease

Emphysema

Eyes, Ears, Nose Throat

Environmental Sensitivities

Fibromyalgia

Gastroesophageal Reflux

Glaucoma

Gout Heart Disease

Infection, Chronic

Inflammatory Bowel Disease

Irritable Bowel Syndrome

Kidney or Bladder Disease

Liver or Gallbladder Disease

Migraine Headaches

Neurological Problems

Sinus Problems

Stroke

Obesity

Osteoporosis

Sexually Transmitted Disease

Seasonal Affective Disorder

Skin Problems

Ulcer

Urinary Tract Infections

Varicose Veins

Thyroid

Other______

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Operations:

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Appendectomy

Prostate

Cholecystectomy

Tonsillectomy

Hysterectomy

______

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Allergies (please list):

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______

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Please list contact information for any and all physicians/facilities that have treated you for conditions related to your pain

Including but not limited to: primary care doctor, surgeon, urgent care facility, emergency room, etc.

Physican/Facility: ______Phone:______Fax:______

Physican/Facility: ______Phone:______Fax:______

Please list any prescription medications, OTCs (over the counter medications), vitamins, minerals, supplements you are taking. Please list the amounts (i.e. 500 mg tablet 2x/day), when you take them (schedule) and why you are taking them. If you need more room, you can attach a list or use the back of this page.

1 ______2 ______

3 ______4 ______

5 ______6 ______

6 ______7 ______

8 ______9 ______

10 ______11 ______

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Physical History: Please check all that apply.

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Head:

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Headaches-one sided

Confusion, Brain Fog

Blurred Vision

Other______

Headaches-involves back of neck

Dizziness, Unsteadiness

Headaches-associated with light sensitivity

Headaches-interfere with work

Change in memory

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Eyes

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Itching

Glaucoma

Sensitive to light

Dryness

Cataracts

Corrective Lenses

Puffy under eyes

Dark circles

Other______

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Ears:

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Hearing Loss

Drainage

Ringing/Roaring

Other______

Pain

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Nose:

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Itches

Runs

Blood streaked mucous

Sneeze

Requires nose drops/spray

Other______

No sense of smell

Sinus infection

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Mouth and Throat

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Snore

Wears dentures

Neck glands swell

Bad breath

Hoarseness

Difficulty swallowing

Sore throats

Grind teeth in sleep

Other______

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Cardiac and Respiratory

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Wheeze

Rapid heart beats

Non-productive cough

Ankle swelling

Bronchitis

Chest pains

Skipped beats

Short of breath

Murmur

Productive cough

Cough up blood

Night sweat

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Gastrointestinal/Digestion

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Heartburn

Cramping

Stomach aches

Rectal bleeding

Belching frequently

Indigestion

Mucous in stool

Anal pain

Diarrhea

Blood in stool

Nausea/Vomiting

Bloating

Excess gas

Constipated

Other______

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Urinary and Genitalia:

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Frequent urination

Kidney stones

Yeast infection

Unsatisfactory sexual relations

Painful urination

Weak stream

Difficulty starting urination

Burning

Pass blood

Genital herpes

Lumps, pain swelling testicles

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Present or previous cancer of the kidneys or urinary tract

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Endocrine

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Fatigue

Heat intolerance

Crave sugar

Reaction time slowed down

Feel puffy or swollen all over your body

Sleepiness in the afternoon

Light headed upon standing

Difficult getting out of bed

Deepening of voice

Cold intolerance

Crave salt

Catch colds or infections easily

Loss of libido

Weight gain for no apparent reason

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Feel cold, chilled-hands, feet all over for no apparent reason

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Musculoskeletal

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Muscle weakness

Morning stiffness

Back pain

Numbness/tingling of hands and feet

Other______

Muscle cramps

Joint swelling, pain or stiffness

Increased redness, warmth of joint

Decreased strength

Muscle twitching

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Parts of the body feel tender, sore, sensitive to touch

Skin:

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Eczema

Easy bruising

Brittle nails

Hives

Dry skin

Other______

Rash

Oily

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Psychological:

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Often unhappy

Difficulty falling asleep

Misunderstood by others

Unable to concentrate

Use tranquilizers

Considered a nervous person

Easily flare in anger

Frequently keyed up and jittery

Am a workaholic

Extremely shy or sensitive

Difficulty staying awake

Other______

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Social History: Please circle all that apply.

Married: Yes NoIf yes, how long______

Children: Yes NoIf yes, how many______

Occupation______

Cigarettes: Yes NoIf yes, how much/day______How many years______

Cigars: Yes NoIf yes, how many/day______or week______

Chewing Tobacco: Yes No

Alcohol: Yes NoIf yes, drinks/day or week______

Coffee: Yes NoIf yes, cups/day______

PMI/FH:

Have you or any of your family members had any of the problems listed in this chart? Please indicate by checking the appropriate box.

Father / Mother / Grandparents / Siblings / Children
Alcoholism
Anemia
Arthritis
Asthma
Cancer
Diabetes
Emphysema
Heart Disease
High Blood Pressure
Osteoporosis
Mental Illness
Thyroid Disorders
Others-List

Please check the boxes below that reflect anysymptoms that you may be experiencing or experienced in the past:

Pain / Numbness / Tingling / Stiffness / Soreness / Weakness / Swelling
Head
Neck
Upper Back
Mid Back
Lower Back
Shoulder
Arm
Forearm
Wrist
Hand
Ribs
Buttock
Hip Thigh
Leg
Knee
Ankle
Foot

Please circle/mark your area(s) of the signs and symptoms listed above.

READ THOROUGHLY BEFORE SIGNING

PATIENT ACKNOWLEDGEMENT OF

RECEIPT OF PRIVACY NOTICE

I hereby acknowledge receipt of the Notice of Privacy Practices for WESTPORT PLAZA PAIN MANAGEMENTregarding my health information. I have been informed and understand the manner in which my health information shall be maintained, utilized and disclosed by Clinic and my respective rights contained there in. I also understand that the Notice furnished to me is subject to change at any time. I am aware that I may obtain a current copy of this Notice at any time on the website or by contacting WESTPORT PLAZA PAIN MANAGEMENT, 3408 Rainbow Blvd Kansas City, KS 66103 (816) 841-4865.

ACKNOWLEGEMENT OF FEES

I hereby acknowledge receipt of notice that Westport Plaza Pain Management does NOT file health insurance claims at this time. I understand that I am personally responsible for payment in full for the care that I receive at the time of service.Westport Plaza Pain Management will provide you with documentation to submit to your insurance carrier so that you may be reimbursed for your medical expenses directly.I further understand and agree that if Westport Plaza Pain Management must take any action to collect an outstanding balance on my account, I will be responsible for payment of and will reimburse this office for all costs of such collection efforts, including but not limited to staff expenses at a rate of $25 per hour, court costs, postage and attorney fees.I agree to the following fee schedule.

Initial Comprehensive Examination $250

Follow up Visits $100

Reproduction of Medical Records $.10 per page

OFFICE WAITING AREA POLICY

Westport Plaza Pain Management, Inc. is a small medical office with very limited space for guests waiting. We have to ask our patients to limit the amount of guests with them to one adult. We apologize for the inconvenience and appreciate your understanding. Additionally there are no foods or drinks other than water permitted in the waiting area. By signing this, you are agreeing to honor these office policies.

CONSENT TO TREAT

I hereby authorize the Doctor’s to treat my case as they deem appropriate through the use of medication, physical therapy, rehabilitation, nutritional support, trigger point injections and diagnostic testing. I realize the goal of healthcare is to strengthen the patient’s body in order to heal themselves.

Patient Signature:______Date:______

NARCOTIC MEDICATION AGREEMENT

You have agreed to receive narcotics for the treatment of your pain. It is important that you have an understanding of the risks and responsibilities that go along with this treatment. Please read each statement and sign this agreement/contract below. If you have any questions regarding this information or the office policy regarding the prescribing of narcotics, please request clarification.

I, ______, understand that:

Any medical treatment is initially a trial, and that continued prescription is based on evidence of benefit. I understand that the goal of using narcotics is to decrease my pain and increase my functional level. If my pain does not significantly decrease and/or my function increase, the medication will be stopped.

I am aware that the use of such medicine has certain risks associated with it, including, but not limited to: sleepiness or drowsiness, constipation, nausea, itching, vomiting, lightheadedness, dizziness, confusion, allergic reaction, slowing of breathing rate, slowing of reflexes or reaction time, kidney or liver disease, sexual dysfunction, physical dependence, tolerance to analgesia, addiction, withdrawal and the possibility that the medicine will not provide complete relief.

The overuse of narcotic medication can result in serious health risks including respiratory depression or even death.

This medication will be strictly monitored and all of my medications should be filled at the same pharmacy. (Should the need arise to change pharmacies our office must be informed). The pharmacy that I have selected is:

Pharmacy: ______

Phone: ______

I understand that my physician will not practice medicine over the telephone. I will not call in to Westport Plaza Pain Management to have my medication refilled. I cannot and will not receive this medication by phone. I will not call the office to have a prescription called in.

I am responsible for making and keeping scheduled appointments on time. Early refill requests will not be honored for any reason.

I will take the narcotic medication only as prescribed. Any changes must first be discussed and agreed upon with the Westport Plaza Pain Management physician.

I understand that medications will not be replaced under any circumstances including but not limited to: if they are lost, stolen, get wet, are destroyed, left on an airplane, discarded by children, dropped in the toilet, etc. It is expected that you will take the highest possible degree of care with your medication and prescription. They should not be left where others (including thieves, children, etc.) might see or otherwise gain access to them. They should never be left in an unattended vehicle! I understand that if I am careless with my prescription or medication and it gets lost, destroyed or stolen, Westport Plaza Pain Management reserves the right to discharge me from the clinic.

I agree that only my physician will prescribe my narcotic medication. I will notobtain or use narcotics or other controlled substances from a source other than Westport Plaza Pain Management. I will instruct my other physicians to confer with the Westport Plaza Pain Management physician for any changes or need for additional narcotic medications. If it is brought to the attention of the clinic that other providers are prescribingmedications for me, the Westport Plaza Pain Management reserves the right to discontinue prescribing medications and/or discharge me from the clinic.

I will inform my Westport Plaza Pain Management physician of any changes in my medical condition, any changes in any prescription and/or over the counter medication that I take and of any adverse effects that I may experience from any of the medications that I take.

I agree to tell my Westport Plaza Pain Management physician my complete and honest personal drug / medication usage and history.

I will not use any illegal “street drugs” while receiving medications from Westport Plaza Pain Management.

I will communicate fully and honestly with my physician about the character and intensity of my pain, the effect of the pain on my daily life, and how well the medicine is helping to relieve the pain.

Routine blood work and random drug screens will be a part of my treatment plan. I agree to have them done on the same day the physician requests it.

Westport Plaza Pain Management, Inc. has my explicit permission to discuss all diagnostic and or treatment details with dispensing pharmacists, any and all physicians that I am currently under care of or was previously treated by, or other professionals who provide my health care for purposes of maintaining accountability.

If the responsible legal authorities have questions concerning my treatment, as might occur, for example, if I were obtaining medications at several pharmacies, all confidentiality is waived and these authorities may be given full access to my records.

It is a felony to obtain narcotic medications under false pretenses. This could include getting medication from more than one doctor, reporting a medication lost or stolen for the purposes of obtaining more medication, misrepresenting myself to obtain medications, using them in a manner other than prescribed or diverting the medications in any other way (selling).

I know that narcotic medications will be stopped if any of the following occurs:

• I trade, sell, or misuse the medication

• The clinic finds that I have broken any part of this agreement

• I do not go for a blood or urine test when asked

• My blood or urine test shows the presence of medications that the staff is not aware of, the presence of illegal drugs, or does not show medications that I am receiving a prescription for

• I get narcotics from sources other than Westport Plaza Pain Management

• Any member of the professional staff of Westport Plaza Pain Management feels that it is in my best interests that narcotic treatment is stopped

• Any aggressive behavior toward physician or staff

• I consistently miss or am late to scheduled appointments

• Arguing with the physician or staff for any reason

It is understood that failure to adhere to this agreement may result in cessation of therapy with controlled substance prescribing (no narcotic prescriptions will be written) by Westport Plaza Pain Management physicians. Additionally, Westport Plaza reserves the right to discharge me from the clinic should I fail to adhere to any part of this agreement.

I have read the Narcotic Medication Agreement and without question understand all of this agreement. By signing this agreement I affirm that I have read, understand and accept all of the terms of this agreement.

Patient signature: ______Date: ______

Clinic Witness: ______Date: ______

**** STAT PATIENT WAITING IN OFFICE ****

PERMISSION TO RELEASE MEDICAL RECORDS

I, , request the release of my medical records:

Please indicate what information you would like released:

ANY AND ALL TREATMENT AND DIAGNOSTIC RECORDS

Said records are to be sent to:

Westport Plaza Pain Management

3408 Rainbow Blvd.

Kansas City, KS 66103

Office: 816-841-4865 / Fax: 816-841-4801

I recognize the material requested is part of my permanent medical record and now hold harmless,

______, from any and all claims resulting from this release.

Patient SignatureDate

Social Security NumberDate of Birth

Witness SignatureDate

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