Please fill in the following information if the subscriber is NOT the patient:

Subscriber DOB:

  Please fill in the following information if the subscriber is NOT the patient:

Subscriber DOB:

Is this a work related injury?

Is this a motor vehicle accident?

     

11. Describe your present pain (i.e. aching, throbbing, sharp, hot, cold, etc.)?
Throbbing	Burning	Numb	Deep
Shooting	Sharp	Tender	Aching
Stabbing	Tingling	Pressure	Cramping
Heaviness	Hot	Cold	Other:

 

12. Describe the timing of your pain:
Constant (Always there)
Intermittent (Comes and goes)
Gets worse as the day goes on

 

13. What do you do to ease or relieve your pain?
Bed Rest	Chiropractor	Massage Therapy	Physical Therapy
Heat/Cold Therapy	Counseling	Biofeedback	Relaxation Therapy
Medication	Exercise Program	Acupuncture	Trigger Point Injections

14. What makes your pain worse?
Coughing/Sneezing	Walking	Exercise	Stair Climbing
Lifting	Hot/Cold Water	Sitting	Standing
Lying Down	Bowel Movement	Damp/Dry Weather	Other:

 

16. What treatment do you think will help to improve your pain problem?

 

17. What percentage improvement do you expect our program to make in your pain?

 

18. Current or former occupation: Working now? Yes    No If no, last day you worked? Are you receiving any kind of disability? If so, what kind?

 

19. Please describe your activities in an average day.

 

20. List the activities you can no longer do because of your pain problem:

 

21. List any diagnostic tests (i.e. MRI, X-RAY, EMG, CT Scan, etc.)you have had related to your pain problem including dates and results:

	Date	Exam	Where Performed	Results
1.
2.
3.
4.

 

22. Are you involved in a legal action related to your pain problem? Yes    No

 

23. Any other legal problems?

 

24. Have you seen another pain doctor for your problem in the past 5 years? Yes    No If Yes, please list the pain doctors’ names:

25. If you have seen a pain management doctor, have you ever had any of the following treatments for your pain problem and what was the result? Please check the appropriate box and give comments.

Treatment Type	Improved	No Change	Worse	When?
Pain Management Doctor Office Visit
Trigger Point Injections
Epidural Steroid Injections
Facet Joint or MBB Injections
Radiofrequency Ablation
SI Joint Injections
Botox Injection
Spinal Cord Stimulation
Any other injections or procedures

26.  Have you ever had any of the following treatments for your pain problem and what was the result? Please check the appropriate box and give comments.

Treatment Type	Improved	No Change	Worse	How Long?	Last Visit When?
Physical therapy
Occupational Therapy
Aquatic/Pool therapy
Passive (heat, ice, gentle massage, ultrasound)
Mobilizations
Traction
Exercises/aerobic conditioning
TENS
Orthotics (i.e. corrective foot inserts)
Prosthetics (braces, supports, etc)
Chiropractic
Deep tissue Massage
Psychological counseling
Alcohol/Drug Detoxification
Extended Bed Rest
Biofeedback or relaxation therapy
Radiation treatment
Acupuncture / Acupressure
Pilates, Tai Chi, Home Exercise
Other (Please describe):

Medication	Dose	Frequency	Date Started	Prescribing Doctor

Have you ever had and allergic reaction to any medication?

(an allergy means a rash, swelling, difficulty in breathing. It does NOT mean causing a stomach upset or dizziness)

If YES please list them:

Tried /Used	Name of Medication	Still Taking	If Stopped, Why?
			Side Effects	Not Effective
	Pain Killers
Yes    No	Codeine, Tylenol #3, #4
Yes    No	Fentanyl patches (Duragesic)
Yes    No	Hydrocodone (Vicodin, Lortab, Norco)
Yes    No	Hydromorphone (Dilaudid)
Yes    No	Methadone
Yes    No	Morphine (MS Contin, Avinza, Kadian)
Yes    No	Meperidine (Demerol)
Yes    No	Oxycodone (Percocet, Oxycontin)
Yes    No	Tapentadol (Nucynta)
Yes    No	Buprenorphine (Butrans, Subutex, Suboxone)
Yes    No	Other:
	Anti-Seizure Medicines/Neuropathic Medications
Yes    No	Carbamazepine (Tegretol)
Yes    No	Duloxetine (Cymbalta)
Yes    No	Gabapentin (Neurontin)
Yes    No	Lamotrigine (Lamictal)
Yes    No	Oxycarbazepine (Trileptal)
Yes    No	Pregabalin (Lyrica)
Yes    No	Tiagabine (Gabatril)
Yes    No	Topiramate (Topamax)
Yes    No	Zonisamide (Zonegram)
	Muscle Relaxants
Yes    No	Baclofen
Yes    No	Carisprodol (Soma)
Yes    No	Cyclobenzaprine (Flexeril)
Yes    No	Diazepam (Valium)
Yes    No	Metaxolone (Skelaxin)
Yes    No	Methocarbamol (Robaxin)
Yes    No	Tizanidine (Zanaflex)
	Anti-Depressants
Yes    No	Amitriptyline (Elavil)
Yes    No	Buproprion (Wellbutrin)
Yes    No	Citalopram (Celexa)
Yes    No	Desipramine
Yes    No	Duloxetine (Cymbalta)
Yes    No	Escitalopram (Lexapro)
Yes    No	Fluoxetine (Prozac)
Yes    No	Hyp. Perforatum (St. John’s Wort)
Yes    No	Lisdexamfetamine (Vyvanse)
Yes    No	Lurasidone (Latuda)
Yes    No	Mitrazepine (Remoron)
Yes    No	Nefazadone (Serzone)
Yes    No	Nortriptyline (Pamelor)
Yes    No	Paroxetine (Paxil)
Yes    No	Sertraline (Zoloft)
Yes    No	Venlafaxine (Effexor)
	Anti-Anxiety
Yes    No	Alprazolam (Xanax)
Yes    No	Chlordiazepoxide (Librium)
Yes    No	Clonazepam (Klonopin)
Yes    No	Diazepam (Valium)
Yes    No	Lithium (Eskalith)
Yes    No	Lorazepam (Ativan)
Yes    No	Oxazepam (Serax)
Yes    No	Phenelzine (Nardil)
Yes    No	Resperidone (Risperdal)
Yes    No	Other:
	Sleep
Yes    No	Eszopiclone (Lunesta)
Yes    No	Temazepam (Restoril)
Yes    No	Trazodone (Deseryl)
Yes    No	Triazolam (Halcion)
Yes    No	Zaleplon (Sonata)
Yes    No	Zolpidem (Ambien)
	Anti-inflammatories
Yes    No	Celecoxib (Celebrex)
Yes    No	Diclofenac
Yes    No	Etodolac
Yes    No	Fenoprofen (Nalfon)
Yes    No	Ibuprofen (Motrin, Advil)
Yes    No	Indomethacin
Yes    No	Ketoprofen
Yes    No	Meloxicam (Mobic)
Yes    No	Naproxen (Aleve, Naprosyn)
Yes    No	Nabumetone (Relafen)
Yes    No	Piroxicam (Feldene)
Yes    No	Salsalate (Mono-Gesic, Salflex, Disalcid)
Yes    No	Sulindac (Clinoril)
Yes    No	Other:

Have you been given opioid (narcotic) medication for your pain? Yes    No

If YES, have they improved your activity or general level of function? Yes    No

If you answered NO to last question, how did the opioid (narcotic) affect your pain level (please choose one): “just take the edge off”    somewhat helpful    quite a bit    very much

Are you taking your pain medications any differently than prescribed by your doctor  (i.e. taking more than prescribed, changing the dosing frequency, not taking them, etc.) Yes    No

If yes, why:

Are you having any problematic side effects? Yes    No

If so, please describe:

Have you or your doctor ever felt that you had a problem with narcotics? Yes    No

Please check YES or NO

Heart:   Yes    No High blood pressure   Yes    No High cholesterol   Yes    No Angina   Yes    No Heart attack   Yes    No Congestive cardiac failure   Yes    No Cardiac surgery   Yes    No Irregular heart beat   Nervous system:   Yes    No Seizures   Yes    No Stroke   Yes    No Paralysis   Yes    No Peripheral neuropathy   Musculoskeletal:   Yes    No Arthritis   Yes    No Neck/back problems   Yes    No Artificial joints (replacement)   Yes    No Other:   Blood Disorder:   Yes    No Anemia   Yes    No Bruising   Yes    No Bleeding Problems   Immune Disorder:   Yes    No HIV   Yes    No MRSA   Yes    No Other:

Lungs:   Yes    No Bronchitis   Yes    No Asthma   Yes    No Shortness of Breath   Liver / Kidneys:   Yes    No Hepatitis   Yes    No Liver problems   Yes    No Kidney problems   Yes    No Bladder problems   Metabolic / Digestive:   Yes    No Diabetes: Insulin or Non-Insulin Dependent?   Yes    No Thyroid disease   Yes    No Acid reflux   Yes    No Stomach ulcer   Yes    No Cancer:   Yes    No Alcohol/Drug Dependency or Addiction   List:   Psychological/Psychiatric:   Yes    No Depression/Anxiety   Yes    No Panic Disorder   Yes    No Post-Traumatic Stress Disorder   Yes    No Other Medical Problems    (Please Describe):

In the past year have you been treated in the Emergency Room for your pain problem: Yes    No

22. Are you involved in a legal action related to your pain problem? 1    2-3    4-6    7-10    More than 10 times

In the past three months, how many times have you been to your regular health care provider or specialist for your pain problem (MD, NP, PA)? Yes    No

Please indicate the number of times: 1    2-3    4-6    7-10    More than 10 times

 

In the past three months how many times have you seen an alternative health care provider for your pain problem (chiropractor, homeopath, naturopath, acupuncturist)? Yes    No

Please indicate the number of times: 1    2-3    4-6    7-10    More than 10 times

Have you had any surgeries? Yes    No

 (If yes, please complete the information below)
  

Name and year of surgery (i.e. lumbar fusion, abdominal surgery)
	Name of Surgery	Year of Surgery
1.
2.
3.
4.
5.

Did you have a happy childhood?	Yes    No
Have you ever been sexually and or physically abused?	Yes    No
Have you ever seriously considered or attempted suicide?	Yes    No
Have you ever been psychiatrically hospitalized?	Yes    No
Have you ever participated in psychotherapy?	Yes    No
Are you currently participating in psychotherapy?	Yes    No
If YES to the above, through which provider(s)?
Do you smoke?	Yes    No
If yes, how much per day?
Do you drink alcohol?	Yes    No
If yes, how many drinks per day/week?
If yes, do you drink to intoxication or binge drink?	Yes    No
If yes, do you drink to decrease your pain?	Yes    No
In the past 10 years have you ever tried street drugs?	Yes    No
Have you or anyone around you ever felt you had a problem with alcohol or drugs?	Yes    No
Have you ever received alcohol or drug treatment?	Yes    No
Have you felt you should cut down on your alcohol or drug use?	Yes    No
Have people annoyed you by criticizing your alcohol or drug use?	Yes    No
Have you ever felt bad or guilty about your alcohol or drug use?	Yes    No
Have you had a drink or used drugs first thing in the morning to steady your nerves or get rid of hangover? (eye opener)	Yes    No

Do you have any of these symptoms? (Please check all that apply)

General:   Fever   Chills   Sweats   Night Sweats   Anorexia   Fatigue Eyes:   Pain   Redness   Blurred Vision   Loss of Vision   Photophobia Ear/Nose/Throat:   Ear Pain   Ringing in Ears   Hearing Loss   Sore Throat   Hoarseness Cardiovascular:   Chest Pain   Palpitations   Shortness of Breath: Exertion   Shortness of Breath: Lying Flat   Claudication, Syncope/Fainting Respiratory:   Cough   Wheezing   Excessive mucous   Shortness of Breath: Exertion   Shortness of Breath: Rest

Gastrointestinal:   Anorexia   Nausea   Vomiting   Diarrhea   Constipation   Change in Bowel Habits   Abdominal Pain   Bloody Stools   Indigestion   Weight Loss Genitourinary:   Painful Urination   Blood in Urine   Urinary Frequency   Incontinence   Decreased Sex Drive Musculoskeletal:   Joint Pain   Joint Swelling   Muscle Cramps   Muscle Aches   Muscle Weakness Skin:   Rash   Itching   Dry Skin Hematologic:   Bleeding   Easy Bruising

Neurologic:   Weakness   Seizures   Tremors   Vertigo   Headaches   Tingling   Numbness   Visual Disturbance   Incontinence Mental Health:   Sleep Problems   Mood Swings   Depressed Mood   Confusion   Suicidal Thoughts   Increased Irritability/Anger   Anxiety/Panic Attacks   Difficulty Concentrating   Hallucinations Endocrine:   Heat Intolerance   Cold Intolerance   Excessive Thirst   Excessive Urination   Constipation   Diarrhea   Dry Skin   Tremor   Excessive Sweating   Changing Menstrual Patterns

Family Member Age (or age at death) Sex Grandparent #1   M    F Grandparent #2   M    F Grandparent #3   M    F Grandparent #4   M    F Father   M    F Mother   M    F Sibling #1   M    F Sibling #2   M    F Sibling #3   M    F Children (Child #1)   M    F Children (Child #2)   M    F Children (Child #3)   M    F

Living? Medical Problems   Yes    No   Yes    No   Yes    No   Yes    No   Yes    No   Yes    No   Yes    No   Yes    No   Yes    No   Yes    No   Yes    No   Yes    No

North Shore Pain Management participates with most insurance plans including Workman’s Compensation, with the exception of MassHealth/Medicaid. Motor VehicleAccidents (MVA) and liens are not acceptable forms of insurance. You must have active health insurance coverage as well.

• "SELF PAY" patients must pay cash for the initial visit, and any consecutive visits, in full at the time of the visit.
• CO-PAYS ARE DUE AT THE TIME OF SERVICE.
• FOR HMO’s - A VALID REFERRAL MUST BE OBTAINED PRIOR TO YOUR VISIT. (Without a valid referral, your appointment may be cancelled and/or rescheduled until the appropriate referral is obtained. Payment for unauthorized services will be required at the time of service.)
• PAYMENT CAN BE IN THE FORM OF CASH, CREDIT CARD, CHECK OR MONEY ORDER.
• You are responsible for any charges incurred in the collection of your account, including, but not limited to legal fees, collection fees, interest or late charges.

Insurance is a contract between you and your insurance company. We are not a party to this contract. We file insurance claims on behalf of our patients. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, pre-existing conditions, etc. other than to supply factual information as necessary. You are responsible for the timely payment of your account.

We will submit claims on your behalf for open workers compensation claims only. It is your responsibility to provide the office staff with accurate workers compensation insurance information as well as your current claims adjuster’s phone number. We will bill your private health insurance if your claim should be denied. Any balance not paid by the worker’s compensation carrier or your private health insurance will be your responsibility.

A fee of $25 will be charged to your account for any/all returned checks(s). All future payments must be made by way of cash or credit card.

To avoid interruption in your plan of care, all past due balances are expected to be paid in full prior to future treatment, unless you have established a mutually agreed upon payment plan.

Each time you make an appointment with any physician, it is your responsibility to make sure your physician is currently under contract with your plan and to obtain the appropriate referral or authorization for your visit. Verification of your insurance plan is required. Therefore, you must provide current insurance information and/or inform our office if there have been any changes to your insurance plan or benefits prior to your appointment date.

We require 24-hour notice for any appointment cancellations. A fee of $40 will be charged to your account for no shows or cancellations of office visits without 24 hour notice. A fee of $100 will be charged to your account for no shows or cancellations of procedures without 24 hour notice. Repeated cancellations or no shows for appointments could result in discharge from the practice.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information that may identify you and that related to your past, present or future physical or mental health or condition and related health care services.
 

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice and any other use required by law.

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Your protected health information will be used, as needed, to obtain payment for our health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing and conducting or arranging for other business activities. We may call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Workers’ Compensation, Inmates, Required Uses and Disclosure. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164-500.

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

The following is a statement of your rights with respect to your protected health information.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administration action or proceeding, and protected health information that are subject to law that prohibits access to protected health information.

This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternative i.e. electronically.

If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at 978-927-7246.