Patient Questionnaire

Integrative Pain Center of Alaska

Dear Patient:
Thank you for choosing Integrative Pain Center of Alaska for your pain management care. We are very happy to have you as a patient and are committed to giving you the best quality medical care possible. This sheet is meant to be a helpful source of information for you.
Please read it thoroughly and initial at the bottom

Please fill out the attached forms completely and return them to be scheduled. Please bring with you any MRI and/or CT films that you may have with you to your appointment. These are an integral part of your evaluation and your appointment may be rescheduled if you do not bring the films with you, or if the attached forms are not completed

We will call you with a reminder the day before your appointment. Should you have any questions before this, please call our office at (907) 374-6602.

In order to provide you with the best possible care we encourage you to make arrangements for child care during your appointment. This will allow your healthcare provider to give you their undivided attention.

We will do our best to assist you in any every way in complying with the particular guidelines of your insurance plan. However, it is ultimately your responsibility to make sure that you have the necessary coverage for any services rendered in our facility.

We are obligated to collect your insurance co-pay at the time of the visit. Every time you see any of our providers you will need to make your co-pay. This includes all follow up visits, discussions regarding any medication you are taking, or medical counseling of any kind.

Some insurance plans ask that you go to a particular facility for tests. This may include laboratories, x-ray facilities and hospitals. We make every effort to send you to the appropriate facility; however, it is your responsible to know if you are limited to a particular facility for these tests and to inform our staff of such. You will need to notify us if your plan requires any pre-certification or prior authorization for any service we provide.This includes office visits, procedures, surgery and physical therapy. Again, you are responsible for getting any pre-certification pr prior authorization if needed. We will assist you with any information you need. For patients from out of town; you may be referred for additional treatment that requires you to stay in Fairbanks overnight. It is your responsibility to arrange for your own accommodations and travel, including taxicabs. If you have Medicaid you must obtain your travel vouchers from your referring physician. IPCA will not arrange your travel.

Thank you,
Integrative Pain Center of Alaska

Initial:

This form is to be completed by all patients before their first appointment. Your careful answers will help us to understand your pain problem and begin the best treatment program for you.

It is understandable that you might be concerned about what happens to the information you provide, as much of it is personal. Our records are strictly confidential and no one outside of your health care team is permitted to your case record without your written permission.


BACKGROUND INFORMATION

Today’s Date: Social Security #:Date of Birth:
Last Name:First Name:
Age in Years:
If you are employed, please describe your job. Occupation
Full-time Part-time Unemployed Disability (list disability):
Are you here for a work-related injury? Yes If yes, how did your injury occur:
Worker’s Comp Carrier: Case Manager Address for Claims:
Case #


Please complete the following information about the Physician that is referring you to our Clinic, along with your Primary Care Physician’s Name, Address, Telephone number, and if possible fax number.

**Important to complete thoroughly so that we can update your referring physician(s) with your treatment plan**

    Referring Physician
    Name:
    Address:
    Phone #:
    Fax #:

    Primary Care Physician
    Name:
    Address:
    Phone #:
    Fax #:


Patient Registration Form
Patient Name: Social Security #:Date of Birth:
Address:
Home Phone #: Cell Phone #:

Marital Status: Married: SingleOther

Gender: Female Male
Race:
Language Spoken(Race and language information used anonymously for public health statistics)
Employer: Business Phone #: Employer Address:
Occupation:
Spouse:
Spouse’s Employer Work #:
Emercency Contact Name (other than Spouse): Relationship: Emergency Contact Home Phone:
Work Phone:


How did you hear about Integrative Pain Center of Alaska, LLC: Referring Physician Yellow Pages RadioTV Other:


PRIMARY INSURANCE INFORMATION: Insurance Co. Name Insurance Co. Address:Insurance Co. Phone#:
Relationship to Patient:
Policy Holder Name: Policy Holder SSN#:Birth Date: Group#: Identification#

WORKER’S COMP INFORMATION: Worker’s Comp Insurance Co. Name W/C Co. Address:W/C Co. Claim#:
Date of Injury:
Employer at time: Name of Adjustor: Adjustor Phone #: Site of Injury:

SECONDARY INSURANCE INFORMATION: Insurance Co. Name Insurance Co. Address:Insurance Co. Phone#:
Relationship to Patient:
Policy Holder Name: Policy Holder SSN#:Birth Date: Group#:
Identification#


I understand that I am fully responsible for any and all charges for services rendered by the Integrative Pain Center of Alaska, LLC. If insurance information is provided, my insurance company will be billed as a courtesy to me. I am responsible for my portion of the bill at the time that services are rendered. I hereby authorize payment under my insurance to be paid directly to Integrative Pain Center of Alaska, LLC providers and I further authorize release of any information necessary to my insurance company for payment of claims. I understand a finance charge of 1.5% will be applied to any outstanding balance due after insurance payment or denial after 90-day grace period.

Date: Patient Signature:

I, the undersigned, hereby authorize Integrative Pain Center of Alaska, LLC providers to examine me, to administer such treatment as is necessary and to perform such procedures as are considered therapeutically necessary.
Date: Patient Signature:


Acknowledgement of Receipt of Notice of Privacy Practices

I, , acknowledge and agree that I have received a copy of Integrative Pain Center of Alaska, LLC’s Notice of Privacy Practices.

PATIENT’S SIGNATURE:
DATE:

PATIENT LEGAL REPRESENTATIVE ( if applicable):
DATE:

PRINT NAME OF LEGAL REPRESENTATIVE:
RELATIONSHIP TO PATIENT:

FOR CLINIC USE ONLY:

Integrative Pain Center of Alaska, LLC made the following good faith efforts to obtain the above – referenced individual’s written acknowledgement of receipt of North of Privacy Practices:

(Identify the efforts that were made to obtain the individual’s written acknowledgement, including the reasons (if known) why the writte acknowledgement was not obtained.)


Click here to read the Health Insurance Portability and Accountability Act


Fiancial Policy
Thank you for choosing us as your Pain Management Specialists. We are committed to your treatment being successful. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment in our office.

All patients (parents or guardians) must complete our Patient Informantion and Fiancial Policy before seeing the Provider.

– PAYMENT IS DUE AT TIME OF SERVICE
– WE ACCEPT CASH, CHECKS AND VISA/MASTERCARD
– WE OFFER A PAYMENT PLAN WITH PRIOR BUSINESS OFFICE APPROVAL
– 10.5% APR ASSESSES ON ALL ACCOUNTS OVER 60 DAYS
– THERE WILL BE A $25.00 SERVICE CHARGE ON ALL NSF CHECKS.

Regarding Insurance:
It is our goal to provide fast and efficient billing as a courtesy to you. We need your help to accomplish this goal by proving complete and accuarte insurance information. Knowledege of your deductible and co-pays is your responsibility. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If for any reason your insurance coverage changes, it is your responsibility to inform Integrative Pain Center of Alaska, LLC in a timely manner. If you fail to inform us within 60 days of the change, the Integrative Pain Center of Alaska, LLC will not be responsible for filing your insurance. Please be aware that some, and perhaps all of the service provided may be non-covered services. Some insurance companies reduce or deny benefits saying they are not considered USR (usual, customary or responsible). Please be advised that our fees are based on a national geographic standart and are, in fact, UCR for Alaska.

All deductibles and co-pays are due and payable at the time of treatment. The balance is your responsibility whether your insurance company pays or not. In the event that your insurance coverage changes to a plan where we are not participating providers, refer to above paragraph.

Usal and Customary Rates
Our Practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s determination of usual and customary rates.

Minor Patients
The adult accompanying the minor, the parents (or legal guardians) of the minor, are responsible for payment.

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.
I have read, understand and agree to this Financial Policy:

Patient’s Name:
Relationship to Patient:
Signature of Parent or Responsible Party:
Date:


Consent For Involvement In Care
In order to comply with specific rules regarding HIPAA, we ask that our patient complete and sign this privacy and security of health information. Unless this Form is completed, we cannot talk to anyone but you.

Billing and Payment Information
I, , herby authorize Integrative Pain Center of Alaska, LLC billing department to speak to the person(s) listed below regarding my billing and payment information.

1. relationship to patient
2. relationship to patient

Medication Information
I, , herby authorize Integrative Pain Center of Alaska, LLC to release prescription that need to be picked up on my behalf to the person(s) listed.

1. relationship to patient
2. relationship to patient

Appointment Reminders
I, , herby authorize Integrative Pain Center of Alaska, LLC and staff to leave appointment reminders by the following methods.

1. Home Telephone/ VoicemailYes No N/A
2. Work Telephone/ VoicemailYes No N/A
3. Cellular Phone/ VoicemailYes No N/A

I understand and assume responsibility of notifying IPCA whenever the listed information changes. I understand this release excludes; insurance companies, attorneys and other health care providers.

PATIENT’S SIGNATURE:
DATE:

WITNESS/ STAFF SIGNATURE:
DATE:

What is your main pain Problem and tell us about how it has been treated


Frequency of Pain Pain level Pain quality Relieves Worsen Unchanged
Constantly 100%
Burning Lying down
Frequently 75%
Throbbing Standing
Intermittently 50%
Dull, aching Sitting
Occasionally 25%
Shooting Walking
Sharp Exercise
Cramping Medications
Pressure Relaxation
Lightning-like Thinking about something else
Cutting Coughing and sneezing
Numbness Urination
Tingling Bowel movement

Review of Symptoms


Please check the symptoms that apply

  • Systemic Symptoms
  • Weight Change
  • Recent illness
  • Night Sweats
  • Headache
  • Facial Pain
  • Sinus Pain
  • Neck Symptoms
  • Lump or swelling in the neck
  • Otolarynngial Symptoms
  • Mouth Sores
  • Difficulty swallowing (dyspagia)
  • Difficulty chewing
  • Dentures currently being worn
  • Dentures improperly fitting
  • Pulmonary Symptoms
  • Shortness of breath
  • Difficulty breathing at rest
  • Difficulty breathing during exertion
  • Sleep apnea
  • Wheezing
  • Cardiac/vascular Symptoms
  • Chest Pain or Discomfort
  • Fast Heart Rate
  • Palpitations
  • Gastrointestinal Symptoms
  • Appetite
  • Recent weight loss (reported)
  • Difficulty swallowing
  • Heartburn
  • Nausea
  • Vomitting
  • Constipation
  • Diarrhea
  • Self-treaded with laxatives
  • Genitourinary Symptoms
  • Dysuria (pain on urination)
  • Increased urinary frequency
  • Urinary loss of control
  • Using incontinence devices
  • Urinary frequency
        times during the night
  • Hematuria (blood in urine)
  • Genital lesion
  • Neurological Symptoms
  • Dizziness
  • Vertigo (turning, whirling sensation, lightheadedness)
  • Fainting (syncope)
  • Weakness
  • Decreased sensation
  • Decreased concentrating ability
  • Memory lapses or loss
  • Endocrine Symptoms
  • Excessive sweating
  • Excessive thirst (polydipsia)
  • Libido has changed
  • Hematological Symptoms
  • Easy Bleeding
  • Bruising
  • Musculoskeletal Symptoms
  • Joint pain, localized
  • Joint stiffness, localized
  • Muscle aches
  • Skin Symptoms
  • Itching
  • Skin lesions
  • Rashes
  • Psychological Symptoms
  • Sleep disturbances
  • Anxiety
  • Depression
  • Previous psychiatric treatment
  • Passing out with needles/procedures
  • Implanted Devices
  • Intravenous Catheter
  • AICD/ Internal Heart Defibrillator
  • Previouse Pacemaker Placement
  • Surgical screws, pins, plates clips, device

Pain History


How long have you had pain? yearsmonths
Did any injury cause your pain? YesNo
If yes what was the date of the injury?

Describe your injury or the history of your pain treatment?
Workman compensation Case ManagerWhere is the pain located?

  • left side
  • right side
  • both sides
  • Face
  • Head
  • Neck
  • Shoulder
  • Arm(s)
  • Wrist(s)
  • Hand(s)
  • Finger(s)
  • upper Back
  • middle Back
  • Chest
  • Abdomen
  • lower Back
  • Leg(s)
  • Feet
  • Pelvic
  • Other

How does the pain limit your activities (Impact your daily life)?
Limits activities
Difficulty walking
Unable to climb stairs
Unable to do chores such as vacuuming or yard work
Unable to walk outdoors on flat ground


How well is your pain controlled? GoodAdequateFairPoor


The Pain is related to: SurgeryAccidentMedical Contition

What previous treatments have you tried?
Acupuncture
Blocks
Chiropractor
Epidural
Injections
Neurostimulator
Pain psychology
Physical Therapy
Spinal Cord Stimulator
Other

Medical History

  • Neurological
  • Seizures
  • Stroke
  • TIA (transient ischemic attack)
  • Multiple Sclerosis
  • Epilepsy
  • Cardiac
  • Heart attack (MI)
  • Arrthymia
  • Palpitations
  • Hypertension
  • Peripheral Edema (Swelling in your legs)
  • Heart valve problem
  • Angina
  • Respiratory
  • Asthma
  • Chronic Bronchitis
  • Chronic Cough
  • History of TB
  • Emphysema
  • CPAP (continuous positive airway pressure)
  • Oxygen therapy
  • Gastrointestinal
  • Ulcers
  • GERD (Reflux)
  • Irritable Bowl syndrome
  • Polyps
  • Colitis
  • Gastritis
  • Diverticulosis
  • Recurrent Infections
  • Bleeding Disorders
  • Hepatic (Liver)
  • Cirrosis
  • Hepatitis
  • Jaundice
  • Elevated liver enzymes
  • Renal (Kidney)
  • Kidney Infections
  • Kidney stones
  • Obstructions (strictures)
  • Reproductive
  • Prostate problems
  • Irregular bleeding
  • Endometriosis
  • Fibroids
  • Endocrine
  • Diabetes
  • Thyroid problems
  • HIV
  • Cancer
  • Type and location:
  • Psychiatric Diagnosis
  • Bipolar disease
  • Depression
  • Schizophrenia
  • PTSD (Post Traumatic Stress Disorder)


Other Injuries

Hospitalizations/ Surgeries

  • Head and Neck
  • Cataract Surgery
  • Brain Surgery
  • Temporal artery biopsy
  • Neck Surgery
  • Carotid Endarterectomy
  • Thyroid surgery/radiation
  • Tonsillectomy (T/A)
  • Cardiac
  • Heart Surgery
  • CABG (Coronary artery bypass grafts)
  • Cardiac catheterization
  • Valve replacement
  • Pacemaker
  • Aortic Repair (Aneurysm)
  • AICD (Internal Defibrillator)
  • Pulmonary
  • Lung Surgery
  • Bronchoscope
  • General Surgery
  • Cholecystectomy (Gallbladder Surgery)
  • Abdominal Surgery
  • Hernia repair
  • Endoscope
  • Colonoscopy
  • Gastric Bypass
  • Kidney (Renal)
  • Nephrectomy (removal of kidney)
  • Lithotripsy
  • Bladder/ Urethra/ Ureter
  • Reproductive
  • Hysterectomy
  • Cesarean Section
  • Tubal ligation
  • Prostate Surgery
  • Orthopedic
  • Shoulder surgery
  • Wrist
  • Hand
  • Hip Surgery
  • Knee Surgery
  • Angle Surgery


Other Surgeries not listed:

Family History

  • Suicides
  • Mental Illness (not retardation)
  • Alcoholism
  • Medication/ Drug abuse
  • Cancer
  • Acute MI (Heart attack)
  • Heart attack prior to age of 50
  • Hypertension
  • Heart Disease
  • Early Death
  • Depression
  • Anxiety
  • Diabetes
  • Bleeding Disorder
  • Family members with Back Problems
  • Neurologic (Brain, Spinal Cord Injury, Multiple Sklerosis)
  • CVA (Stroke)
  • TIA (mini Stroke)

Social History

Marital StatusMarriedDivorcedSingleLiving with significant other
Children: Ages:

    Second Hand Smoking:

  • Current
  • Current former
  • Never
  • Parent
  • Partner
  • Roommate
  • Spouse
    Smoking Status:

  • Current every day
  • Current some days
  • Former
  • Never
  • 40 pack/year history

Cessation Intervention

Type:Cigarettes
        Cigars
        Smokeless

Packs a day:

Alcohol
Type:Wine
        Beer
        Hard Liquor
Drinks per Day:

Caffeine:
Quantity:cups/day

Employment:

Occupation:


Please click here to fill out the DRAM

DRAM Score 1:
DRAM Score 2:
DRAM Score Total:

PDQQ-S


For Question 3a and 3b please pick an activity that you realistically would like to reach with treatment
Please move the dot on the line that best describes the problems you have had asa result of your average index pain over the past 7 days.



1. How severe has your index pain been?
no painworst possible pain
0
2. How often has your index pain been present?
never presentalways present
0
3. Because of your index pain, how difficult is it for you to do each of the following activities?
a.

0
b.
4. If you had to live with your present level of pain for the rest of your life, how satisfied would you be?
completely satisfiedcompletely unsatisfied
0
5. How much has your index pain disrupted the quality of your life?
not at allcompletely ruined it
0