EFTA00313804.pdf

well Cornell Medicine Center for Comprehensive Phone: (888) 922-2257 (888-WC-BACKS) Spine Care Please return this form to our office via fax. (646)962-0640 n 'For Eric Bowl% MD; Kai-Ming Fu, MD; and Attn: Jude Anthony A Garcia All A. Baal, MD; please return forms to (646) 962-0119 Please note which department or physician you are reques ting to see: 1‘11 • k ART L_ Neurosurgery Neurology Pain Management Physiatry/Rehab Medicine NEW PATIENT QUESTIONNAIRE DATE: dAhl-1 Tl ao Patient Name: C-- re171 Date of Birth: Cl / / I 9 53 Gender: M Phone Number: ddress: 9 GAS? —413r sr, N Y it! Referred by h local 1. LA h t Insurance Carrier/ ID or Policy Il i 4t1I -Tr> ii•EAL;THCA Reason for Visit: Have you had a history of accident or injury? If yes, please explain and answer the next three questions: • Was the accident at work? Yes or No • Are you using Workman's Compensation? Yes or No • Are you currently involved in litigation? Yes or No On the diagram below, please mark where you are feeling your symptoms with the appropriate letters. On a scale of 0 to 10, please circle your level of pain or discomfort RIGHT LEFT 0 being none and 10 being unbearable for the following areas: LEFT RIGHT 1. Neck Pain: 0 1 2 3 4 5 6 7 8 9 10 2. Left Shoulder Pain: 0 1 2 3 4 S 6 7 8 9 10 3. Right Shoulder Pain: 0 1 2 3 4 5 6 7 8 9 10 4. Left Arm Pain: 0 1 2 3 4 5 6 7 8 9 10 5. Right Arm Pain: 0 1 2 3 4 6 7 8 9 10 6. Back Pain: 0 1 2 3 4 6 7 8 9 10 7. Left Hip/Buttock Pain: 0 1 2 3 4 6 7 8 9 10 8. Right Hip/Buttock Pain: 0 1 2 3 4 6 7 8 9 10 9. Left Leg Pain: 0 1 2 3 4 6 8 7 9 10 10. Right Leg Pain: 0 1 2 3 4 6 7 8 9 10 A-. ACHE 11. Left Foot Pain: 0 1 2 3 4 S 6 7 8 9 10 B= BURNING 12. Right Foot Pain: N= NUMBNESS 0 1 2 3 4 5 6 7 8 9 10 F.= PINS/NEEDLES S= STABBING If you are not experiencing pain as a symptom, 0= OTHER please skip Questions 1-7. Please note if other: I. When did the pain begin? 3. What makes the pain better (cheek all that applies)? I lent Cold Bend Forward Duration of Pain: Bend Back Change Position Sitting Standing Walking Twisting Overall the pain is: Movement Change in weather Lying Supine Rest Valsalva Coughing/Sneezing Improved Worse Stable Nothing Sex N/A 2. Quality of Pain (Cheek all that applies)? 4. What makes the pain worse (check all that applies)? Sore Aching Burning I leaf Cold Bend Forward Sharp Dull Bend Back Change Position Sitting Tender Stabbing Tingling Standing Walking Twisting Cramping Shooting Pulling Movement Change in weather Lying Supine Radiating Unsure Throbbing Rest Valsalva Coughing/Sneezing Nothing Sex N/A 1 EFTA00313804  5. Pain interferes with: 7.11pain limits activity, please full in all that apply: Sleep Appetite Sex Self-Care I lobbies Job Performance I can't tolerate walking more than blocks. Driving Social Life Exercise I can't tolerate sitting more than Lifting minutes. Traveling Shopping household Chores I can't tolerate standing more than minutes. Cooking Other I can't tolerate lying more than minutes. 6. When Is the pain worst? (Circle one) 8. Do you experience weakness? Yes or No Morning Afternoon Evening Night If yes, please describe (include location) Have you had any of the following imaging studie s? If yes, please include the date. IF SO, PLEASE FORWARD A COPY OF THE REPORT TO THE OFFICE PRIOR TO YOUR APPOINTMENT! X-ray Bone Scan MRI tYtt. ILF,ao CT scan EMG NICV.2 , a Oi Below, indicate past treatments for your neck/b ack condition and include the date of treatment: bR if aid Nerve Block Steroid Injections of QCI1 Jtn4C Physical Therapy Psychotherapy Acupuncture Surgery Chiropractic Failed Medications Other If surgery is recommended, what would be your timeframe available for scheduling? REVIEW OF SYSTEM% GENERAL ENDROCRINE Fatigue o NO o YES NEUROLOGICAL Thyroid condition 7 NO 0 YES Dizziness/Vertigo a NO o YES Weight loss a NO a YES Diabetes C NO Il YES Headaches o NO a YES Weakness a NO o YES Other Strokes c NO a YES Swollen Lymph nodes a NO a YES Seizures o NO o YES KIDNEY Tremor o NO o YES HEAD Difficulty in passing urine o NO a YES Numbness o NO a YES Visual problems a NO ci YES Getting up at night to urinate o NO o YES Ear pain, decreased hearing a NO o YES Difficulty swallowing o NO a YES PSYCHOLOGICAL GASTROINTESTINAL Anxiety o NO a YES Other Poor appetite C NO 0 YES Depression a NO a YES Indigestion or vomiting 0 NO 0 YES Other CHEST, HEART, AND LUNGS Shortness of breath o NO c YES Change in bowel habits 0 NO 0 YES Chest pain or pressure attacks a NO a YES Pass blood from rectum 0 NO 0 YES History of Cancer? Yes No Frequent cough a NO o YES If yes, type: Swollen ankles a NO o YES MUSCULOSKELETAL Chemo: Yes No Valve disorder o NO a YES Decreased Range of Motion a NO o YES Radiation: Yes No Sleep Apnea o NO o YES Joint Swelling o NO a YES DVT a NO a YES Joint Stiffness o NO a YES Please notify the MD/NP/PA/RN If you are Stents o NO o YES Muscle Aches/Pains a NO o YES pregnant: Yes No Other 2 EFTA00313805  Current Medication: Dosage: Frequency: 1. Any allergies to: Shellfish Iodine Latex Contrast/IV dye 2. Allergies Reaction 3. 1. 4. 2. 5. 3. 6. 7. 8. ,octal History: 1. Are you a: Current Smoker / Never Smoker / Forme r Smoker Quit Date: Type: Packs/day: Years: 2. Do you use chewing and/or smokeless tobacco? Yes or No Have you quit? Yes or No When? 3. Do you drink alcohol? Yes or No Type(s): Amount: How often: 4. Do you use illicit street) drugs? Yes or No Type(s): Last used: 5. Marital Status: C Married Cohabitating Separated Divorced Widowed 6. Who do you live with? Alone Spouse Childre n Parents Other: 7. What is your occupation? 8. Are you disabled? Yes or No If yes, note disabi lity: Medical/Personal History: Are you right- or left-handed? Right Left Ambidextrous Past Medical History: Past Surgical History and Dates: Family Medical History: Please share any other information you would like us to know: Preferred Pharmacy: Name: Phone Number: Address: If this form was completed by someone other than the patient, please list the name, relation to the reason that the patient was unable to complete the patient and the form. Form Completed by Date 3 EFTA00313806  WeilCamelMedicine Center for Comprehel Spine Care Oswestry Disability Questionnaire This questionnaire has been designed to give us informat answer by checking one box in each section for the statemeion as to how your back or leg pain is affecting your ability to manage in everyday life. Please any one section apply but please just shade out the spot that nt which best applies to you. We realize you may consider that two or more statements in indicates the statement which most clearly describes your problem. Section 1: Pain Intensity Section 6: Standing o I have no pain at the moment o The pain is very mild at the moment o I can stand as long as I want without extra pain o The pain is moderate at the moment o I can stand as long as I want but it gives me extra pain o Pain prevents me from standing for more than hour o The pain is fairly severe at the moment 1 o The pain is very severe at the moment o pain prevents me from standing for more than 30 minutes o The pain is the worst imaginable at the momen o Pain prevents me from standing for more t than 10 minutes o Pain prevents me from standing at all Section 2: Personal Care (eg. washing, Section 7: Sleeping dressing) o My sleep is never disturbed by pain I can look after myself normally without causing o My sleep is occasionally disturbed by pain extra pain o I can lock after myself normally but it causes o Because of pain I have less than 6 hours sleep extra pain o It is painful to look after myself and I am slow o Because of pain I have less than 4 hours and careful sleep o I need some help but can manage most of o Because of pain I have less than 2 hours my personal care sleep o I need help every day in most aspects of o Pain prevents me from sleeping at all self-care o I do not get dressed, wash with difficulty and stay in bed Section 8: Sex Life (if applicable) Section 3: Lifting o My sex life is normal and causes no extra pain o I can lift heavy weights without extra pain 0 My sex life is normal but causes some extra pain c I can lift heavy weights but it gives me extra o My sex life is nearly normal but is very painful pain o Pain prevents me lifting heavy weights off O My sex life is severely restricted by pain the floor but I can manage if they are conveniently placed (eg. on o My sex life is nearly absent because of pain a table) o Pain prevents me lifting heavy weights but c pain prevents any sex life at all I can manage light to medium weights if they are conveniently position ed o I can only lift very light weights Section 9: Social Life I cannot lift or carry anything o My social life is normal and gives me no Section 4: Walking* extra pain o My social life is normal but increases the degree of pain o Pain has no significant effect on my social life apart from o Pain does not prevent me walking any distanc limiting my more energetic interests e.g. sport e o Pain prevents me from walking more than 1 mile o Pain has restricted my social life and I do not o Pain prevents me from walking more than go out as often 'A mile o Pain has restricted my social life to my home o Pain prevents me from walking more than o I have no social life because of pain 100 yards o I can only walk using a cane or crutches o I am in bed most of the time Section 10: Travelling Section 5: Sitting o I can travel anywhere without pain o I can travel anywhere but it gives me extra pain o I can sit in any chair as long as I like o Pain is bad but I manage journeys over two hours o I can only sit in my favorite chair as long as I o Pain restricts me to journeys of less than one like hour o pain prevents me sitting more than one o Pain restricts me to short necessary journeys under hour 30 o Pain prevents me from sitting more than minutes 30 minutes o Pain prevents me from sitting more than o Pain prevents me from travelling except 10 minutes to receive treatment o Pain prevents me from sitting at all EFTA00313807  Weil Cornell Medicine Center for Cn Spine Cart- Neck Disability Index This questionnaire has been designed to give us information as answer every section and mark in each section only the one to how your neck pain has affected your ability to manage in one section relate to you. but please just mark the box box that applies to you. We realize you may consider that two everyday life. Please that most CJosety describes your problem. or more statements in any Section 1: Pain Intensity Section 6: Concentration o I have no pain at the moment I can concentrate fully when I want to with o The pain is very mild at the moment no difficulty o The pain is moderate at the moment o I can concentrate fully when I want to with slight difficult y o I have a fair degree of difficulty in concentrating o The pain is fairly severe at the moment when I want o I have a lot of difficulty in concentrating when o The pain is very severe at the moment I want o The pain is the worst imaginable at the momen o I have a great deal of difficulty in concentrating t when I want o I cannot concentrate at all Section 2: Personal Care (Washing, Dressing, Section 7: Work etc.) o I can do as much work as I want to o I can look after myself normally without causing extra 01can only do my usual work, but no more pain o I can look after myself normally but it causes extra o I can do most of my usual work, but no more pain o It is painful to look after myself and I am slow and o I cannot do my usual work careful o I need some help but can manage most o I can hardly do any work at all of my personal care o I need help every day in most aspects of self o I can't do any work at all care o I do not get dressed. I wash with difficulty and stay in bed Section 8: Driving Section 3: Lifting o I can drive my car without any neck pain o I can lift heavy weights without extra pain o I can drive my car as long as I want with slight pain o I can lift heavy weights but it gives extra pain in my neck o Pain prevents me lifting heavy weights off the o I can drive my car as long as I want with floor, but I can moderate pain in my manage if they are conveniently placed, for examp neck le on a table o Pain prevents me from lifting heavy weights o I can't drive my car as long as I want becaus but I can e of moderate manage light to medium weights if they are conven pain in my neck iently positioned o I can hardly drive at all because of severe o I can only lift very light weights pain in my neck o I can't drive my car at all o I cannot lift or carry anything Section 9: Sleeping Section 4: Reading o I can read as much as I want to with no I have no trouble sleeping pain in my neck o My sleep is slightly disturbed (less than 1 hr sleeple 01can read as much as I want to with slight pain in o My sleep is mildly disturbed (1.2 hrs sleeple ss) my neck ss) o I can read as much as I want with moderate pain o My sleep is moderately disturbed (2-3 hrs in my neck sleepless) o I can't read as much as I want because o My sleep is greatly disturbed (3-5 hrs sleeple of moderate pain in ss) my neck o My sleep is completely disturbed (5-7 hrs sleepless) o I can hardly read at all because of severe pain in my neck o I cannot read at all Section 10: Recreation Section 5: Headaches o I am able to engage in all my recreation activitie s with no neck pain at all O I have no headaches at all o I am able to engage in all my recreation activitie o I have slight headaches. which come infrequ s, with some ently pain in my neck o I have moderate headaches. which come infrequ o I am able to engage in most, but not all of my ently usual o I have moderate headaches, which come frequen recreation activities because of pain in my neck tly o I have severe headaches, which come frequen 0 I am able to engage in a few of my usual recreat tly ion activities o I have headaches almost all the time because of pain in my neck o I can hardly do any recreation activities because of pain in my neck o I can't do any recreation activities at all EFTA00313808  Weill Cornell Medicine Financial Policy Thank you for choosing Weill Cornell Phys icians for your health-care needs. The following is our payment poli cy which we require you to read and sign prior your visit(s). Patients have many different types of insurance and payment options for serv practice accept the same type of insuranc ices rendered. Also, not all physicians in e. To ensure that we have accurate info the copy of your medical insurance and rmation to process your claim, we will mak /or Medicare card at the time of you ea r appointment. You are required to inform us immedia tely of any changes in demographic info Patients without medical insurance rmation or medical insurance informat are required to pay in full at time of ion. service. We understand that financial hard ships may affect your ability to pay work with you. Please ask to speak to in full. We will always do everything our Site Manager to discuss a satisfac we can to tory arrangement. Participating Plans You must present your insurance card, and if applicable, your insurance refe directly to your insurance company for rral form, at every visit. We will submit payment on your behalf. Patients with bills asked for full payment at time of service. out insurance cards or proper referrals All co-pays, deductibles and non-cov will be ered services will be collected at time of service. Non-Participating Plans If your provider does not participate in your insurance plan, you are resp service. We can submit the claim dire onsible for payment of all charges at ctly to your carrier or a claim can be the time of mailed to you. Payment in full is due at the time of serv ice for all non-medically necessary serv ices and/or cosmetic services. Usual and Customary Rates Your insurance policy is a contract betw een you and your insurance company treatment for your patients and we char . Our practice is committed to providing ge what is usual and customary for our the best regardless of any insurance company area. You are responsible for payment 's arbitrary determination of usual and customary rates. Payment For your convenience, the following payment methods are accepted: Cash, personal check, Visa, MasterCard, American Express, Discover I have read the policy, I understand and agree to it. Patient Signature TALI- Date p )eFFi JA,J. IR- Q.-401 Patient Print Date EFTA00313809  Weill Cornell Physicians Notice of Physician Non-Participation in Your Health Plan Dear Patient You are scheduled for a visit today with a Weill Cornell Physician that does not part health plan. By signing this document you icipate with your acknowledge that the provider does not health plan and therefore this and any othe participate in your r visits or services from this provider may covered by your health plan. result in costs not If you agree to receive healthcare services from this provider, you are entitled to the physician charges for the anticipated request an estimate of services associated with this visit or any planned procedure. Many Weill Cornell Physicians participa te in various health plan networks, altho participates in every plan. You can find a ugh not every physician list of the plans in which each physician parti searching their name here: htto://weillco cipates by rnell.org/ under the tab "insurances". By providing your signature below, you acknowledge that you have agreed to visits participating provider. with a non- Signature of Patient or Patient's Represe ntative Date EFTA00313810  Weill Cornell Medical College (WCMC) Privacy Office Forms Authorization To Disclose Health Information Via E-Mail Patient Name: -TIE1-71 fa.e c_--ps-raIN) MARV: Street q EAST "7-0-r DOS: City: k ‘I ST: N") Zip: C Cat Phone: This authorization covers protected health information (PHI) disclosed personnel to a patient or a patients by Weill Cornell Medical College (WCM representative through e-mail comm C) communicate via e-mail is no longer unication. It expires when the need necessary, when the patient changes to revokes S. his/her e-mail address. or if the patie nt *teed64. To be completed by patient or patie nt's representative: My signature at the bottom of this form is authorization for WCMC to disclose named patient via e-mail. It also the health information of the abov confirms my understanding that: e- • Information sent via e-ma il is not considered secure. There is the poss health Information or the risk that who has access to your e-mail acco it may be disclosed or seen by an unintibility of re-disclosure of the personal ended recipient, such as any person unt. Re-disclosure may no longer • I should not use e-mail for any urgen be protected by law. t or time-sensitive medical questions • Once transmitted, I am responsible or issues for safeguarding the information I recei • I have the right to revoke ve this authorization at any time before Privacy Office a WCMC Revocation information is disclosed by submitting of Release of Medical Information Form to the not apply to information that has 0 PO012S. A revocation vnll • alrea dy been relea sed as a resul t of this authorization To initiate e-mail communication, I will send an e-mail from my e-mail information, to the WCMC party at the address. containing my request for e-mail address below • I am responsible for notifying the WCMC party listed below if my another authorization in order to comm e-mail address changes and completing • unicate using a different addre If I am communicating via e-mail abou ss t someone else. I attest that I am respo payment and will indicate my relationsh nsible for that persons care or ip to the patient below • WCMC will not condition treatm ent or payment upon receipt of an autho rization The e-mail address I wish to use is: • jeeVa eciti on ecT O nr, • ck nn PatienVRepresentative Signature J 4 IC • Date If the patient listed above is a minor or is unable to sign, and you are representative who will use e-mail to a parent. legal guardian, or personal communicate about this patient, pleas e sign above and complete the following: Print name Relationship to patient .110••••1111. To be completed by WCMC: Name of WCMC party (please print) : WCMC e-mail: WCMC. please indicate date completed: request in the patients Me. and provide . retain a copy of this a copy of the original to the requeslor PO0268 FM Auth Email 090115 Page 1 of I Eff: 111445 Rev 1011/07 Rev: 1/15/09 EFTA00313811