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PATIENT HISTORY FORM Date:___________________

Patient Name:_____________________________ Date of Birth__________ AGE: ______

******Primary Care Provider: ____________________________________

What medical problem brings you to our clinic?

______________________________________________________________________

______________________________________________________________________

When did this begin?

______________________________________________________________________

What do you think caused it? (Circle One) Work Injury Auto Accident Other

Please describe (For Auto accidents/Work Injury, please complete Auto

Accident/WorkInjury Form)_________________________________

Social History:

Martial Status: Single Married Divorced Widowed Separated

Employment (Please Circle)

Employed Student

Self-Employed Homemaker

Retired Unemployed

If employed where: ____________________How Long in this position_______

What is your job title? _______________________________________

What are your specific duties?______________________________

Exercise: Type:_______________ Frequency: _______________________

How many Alcohol drinks do you have per week? ____________

Do you smoke? Yes No How many packs/day? __________

Do you use street drugs? Yes No

Do you use Marijuana? Yes No Medicinal or Recreational

How much________________

What Type? (Circle One) Smoke Edible Hash Oil

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Please list all medications you are currently taking

Do you take any blood thinning medications such as: Aspirin, Coumadin/Warfarin, Aggrenox, Effient, Lovenox, Plavix,

Pletal, Pradaxa, Eliquis, Xarelto, Treutal, etc.

______yes or ____no, If yes, Which one____________________ Prescribing MD_______________

Medication name and dose: Frequency:

_______________________________________________________________________

______________________________________ _________________________________

______________________________________ _________________________________

______________________________________ _________________________________

______________________________________ _________________________________

______________________________________ _________________________________

______________________________________ _________________________________

Do you have any known drug allergies? List medication and reactions:

________________________________________________________________

________________________________________________________________

________________________________________________________________

Topical Allergies: ____Iodine _____ Latex _____Tape

Previous Diagnostic exams

Which body part? Date completed Facility imaging done at?

MRI

CT Scan

X-ray

Past Medical History (Circle all that apply)

Musculoskeletal:

Back Pain Chronic Neck Pain Raynaud’s phenomenon

Bursitis Costochondritis Reflex sympathetic dystrophy

Carpal tunnel syndrome Fibromyalgia Scoliosis

Cervical disc syndrome Muscular dystrophy Spinal stenosis

Chronic Joint Pain Osteoarthritis Trigger finger

Chronic musculoskeletal pain Osteoporosis Vertebral compression fracture

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Neurology:

Alzheimer’s Head Injury Neuropathy Syncope

Bell’s Palsy Headache Parkinson’s disease Trigeminal Neuralgia

Cerebral Palsy Multiple Sclerosis Epilepsy

Psychiatry:

Anxiety Drugs abuse (illegal drugs) Posttraumatic stress disorder

Hyperactivity disorder Drug abuse (prescription drugs) Schizophrenia

Bipolar disorder Insomnia Suicidal Attempt

Chronic Fatigue syndrome Obesity Depression

Obsessive-compulsive disorder

Rheumatology:

Fibromyalgia Lupus Myasthenia Gravis

Gout Mixed Connective tissue disease Rheumatoid Arthritis

Respiratory:

Asthma Emphysema Pulmonary hypertension

Chronic bronchitis Pneumonia Sleep apnea

COPD Pneumothorax Spontaneous Tuberculosis

Cystic Fibrosis Pulmonary edema Tuberculosis

Diffuse interstitial lung disease pulmonary embolism

Cardiovascular:

Aneurysm Deep vein thrombosis Myocardia infarction

Angina Heart Block, complete Myocarditis

Aortic Stenosis Heart Block, 2nd degree Palpitations

Atrial fibrillation High Cholesterol Pericarditis

Atrial flutter High Triglycerides Peripheral vascular disease

Atrial sepal defect Hypertension Syncope

Congestive heart failure Murmur Varicose Veins

Coronary artery disease Mitral valve prolapse

Gastroenterology:

Appendicitis Gastritis Liver abscess

Cirrhosis Gastro esophageal Reflux Pancreatitis

Constipation Hemorrhoids Peptic Ulcer Disease

Cohn’s disease Hepatitis Gallbladder Disease

Jaundice

Genitourinary:

Bladder Incontinence Nephrolithiasis Urinary tract infection

Erectile dysfunction Renal failure

Hydrocele Urinary incontinence

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Endocrine:

Addison’s disease Grave’s disease Thyroid nodule

Crushing’s disease Hyperthyroidism

Diabetes Hypothyroidism

Infectious Disease:

AIDS Herpes Measles

Cellulitis Influenza Meningitis

Hepatitis Lyme Disease Pneumonia

Surgical History:

Adenoidectomy Cataract surgery: Left Right Hip Replacement: Left Right

Amputation Which Limb:______ Colectomy Hysterectomy

Angioplasty Colon resection Knee replacement: Left Right

Appendectomy Coronary artery bypass graft Laminectomy

Arthroscopy Fistula repair Mastectomy

Biopsy (Of what _________) Foot Surgery Left Right Oophorectomy

Breast augmentation Fracture: ___________ Orthopedic Surgery: ________

Bypass graft Caesarean section Gallbladder surgery

Spinal Surgery: ___________ Carpal Tunnel Release Hemorrhiodectomy

Thyroidectomy Hernia Repair Tracheostomy

Family History

Mark all appropriate diagnosis as they pertain to your biological Mother and Father only:

Arthritis Cancer Diabetes Headaches

Heart

Disease

Kidney

problems

Liver

problems Osteoporosis

Rheumatoid

arthritis Seizures stroke

Mother

Father

I am adopted: ___________ I have no significant family medical history: _____________________

Review of System: (Circle all that you currently have)

General:

Change in appetite Excessive sweating Low sex drive

Chills Excessive thirst Malaise

Difficulty Sleeping Fatigue Night Sweats

Easy bruising Insomnia Tremors

Musculoskeletal:

Limitation of motion Muscle wasting Swelling, Joint

Muscle cramps Muscle weakness

Muscle spasms Stiffness

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Neurological:

Abnormal gait Involuntary movement Tingling

Carpal tunnel syndrome Memory Loss Tremors

Disorientation Numbness Weakness

Dizziness Paralysis Fainting

Seizure

Gastrointestinal:

Acid reflux Diarrhea Gallstones

Belching Fecal incontinence Nausea

Bloating Flatulence Vomiting

Constipation Food intolerance

Psychiatric:

Anxiety Irritability Panic Episodes

Depression Memory Changes Suicidal Thoughts

Review of System: (Circle all that you currently have)

HEENT:

Blurred vision Eye pain nasal discharge

Cataracts Facial pressure Nose bleeds

Color blindness Glaucoma Ringing in the Ears

Deafness Hoarseess Runny Nose

Double vision Loss of smell Sinus problem

Earache Metallic taste Toothache

Excessive tearing Nasal congestion

Respiratory:

Cough Short of Breath Wheezing

Exposure of TB Snoring

Cardiac:

Chest Pain Fainting

Edema Lightheadedness

PATIENT SIGNATURE: _______________________________________

REVIEWED WITH PATIENT: ___________________________________

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PREVIOUS TREATMENT:

What treatment(s) have you had for this problem so

far?See below:

MEDICATION MANAGEMENT :

o LIST MEDICATIONS TRIED AND FAILED

_________________________________________

_________________________________________

PREVIOUS INJECTIONS OR SURGERY:

_________________________________________

PHYSICAL THERAPY:

o WHERE AND HOW LONG WAS THE TREATMENT

_________________________________________

_________________________________________

CHIROPRATIC TREATMENT

o WHERE AND HOW LONG WAS THE TREATMENT

_________________________________________

_________________________________________

What percent improvement have you had since onset

(0-100%)? ________%

PAIN SCALE:

On a scale in which 0 is no pain and 10 is the worst pain

you can imagine, please rate your pain:

Today (0-10)_______Best (0-10) ________

Worst (0-10)______ Usually(0-10)________

How long can you – Sit: ____Stand:___

Walk:___Drive:___

How much to you think you can currently lift?_____lbs

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Patient Name: _______________________ Date of Birth:______________Date of Service: _______ Mark these areas on your body where you feel these sensations Please use these Symbols: Numbness Pin and Needles Ache Pain ====== ooooo xxxxx ///// ====== ooooo xxxxx ///// ====== ooooo xxxxx /////

Anterior Posterior

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Patient Treatment Contract Patient’s name:_____________________DOB____________ Date____________

*By signing this agreement, I authorize Dr. Scott R. Ross to administer treatment and medication that is deemed necessary and advisable in the treatment and diagnosis of my condition(s). Narcotic Policy: *** Please Read Carefully – this policy is for your Safety ***

When appropriate after a thorough review of your medical history, failure of conservative medical and surgical management, it may be determined that you require narcotic medications for your chronic pain condition. You have been told of the risks, complications, and side effects of the medications, prior to proceeding with the therapy. This contract applies to all medications: Narcotic and Non-Narcotic, prescribed by Dr. Scott R. Ross. By signing below, you agree therapy and termination of treatment with Dr. Scott R. Ross. This is a legally binding contract and must be signed below.

I agree to the following terms and conditions in this contract:

When appropriate, Dr. Scott R. Ross may prescribe narcotic medications to treat pain (i.e. Vicodin, Percocet, OxyContin, etc.).

I will NOT obtain or consume narcotic drugs from other sources while under Dr. Scott R. Ross’s care. I will not ask ANY other physician to fill my narcotic medications from Dr. Scott R. Ross. I will not go to Urgent Care, Emergency Room, or any other medical practitioner and obtain narcotics without informing Dr. Scott R. Ross within one business day. I will notify the office of Dr. Scott R. Ross immediately if I obtain narcotics from any other provider.

I understand that I will need to pick up my prescription in person. ***********

I will not sell, share, or give any of my medications to another person; I understand that such a mishandling of my medications is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.

Lost or stolen prescriptions will not be replaced without a police report. This will only be allowed once. The medications will also NOT be replaced if lost or stolen for any reason unless a police report is obtained.

I will take my medications EXACTLY as prescribed by Dr. Scott R. Ross. I will not alter the way I take it without consulting with Dr. Scott R. Ross.

Dr. Scott R. Ross will not prescribe or refill narcotic medications over the phone. I realize that an office visit is required to request a medication/prescription changes until the next scheduled visit.

I will be required to fill out a visual analog pain scale questionnaire at every office visit.

I agree and consent to random urine drug screening at ANYTIME during my treatment with narcotics. I agree to pay ALL COSTS associated with the medications, the drug screens, physician office visits, and ANY COSTS associated with the Narcotic Treatment Program. I agree to follow up in one month intervals for medication refills. I agree that my functional status will be assessed at frequent intervals and if it is determined that medications are not working, they will be stopped.

I will keep my narcotic medication (s) in a safe and secure location and out of reach of children.

I will notify my physician of ANY side effects immediately. If I experience any sedation symptoms I will notify Dr. Scott R. Ross.

If I test positive for any illegal drugs, my narcotic medication may be stopped.

Prescribed narcotics are monitored by the Colorado Prescription Drug Monitoring Program (PDMP). We will obtain routine Colorado CPMP reports to validate that our patients are adhering to our policy of only obtaining narcotic based pain medications for our office.

Patients who are prescribed narcotics require a three-month office follow up visits to be evaluated. These visits should be scheduled well in advance of prescription(s) running out.

Dr. Scott R. Ross will only prescribe up to one-month supply of narcotic medications at each visit.

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I will only use one pharmacy for ALL my prescriptions and will advise Dr. Scott R. Ross immediately if this changes. My pharmacy name and phone number are as follows: ***________________________ ________________ Pharmacy Name Phone Number ANY violation of this narcotic policy may result in Dr. Scott R. Ross discharging me from his practice.

Appointment Policy: Canceled Appointments/No Show Appointments: As a courtesy to Dr. Scott R. Ross, and other patients, please provide at least 48 hrs. when cancelling an appointment. Appointments cancelled less than 48 hrs. in advance will be subject to a $50 cancellation fee. Patients, who are more than 15 minutes late for an appointment, may be asked to reschedule. If you NO SHOW/Cancel appointment without calling within 48 hrs one will be subject to a $50.00 No Show Fee. If you NO SHOW without calling or to call cancel appointments three times – discharge from the practice will follow.

Medication Refill Policy: Medication renewals are NOT a medical emergency. As a patient, I am responsible for ensuring that I stay current on my medications and advise Dr. Scott R. Ross’ office of refill requests at least one week prior to running out of medication. Please allow up to 3 to 4 days for refills to be processed.

Arbitration Agreement

Signing the Arbitration Agreement is part of this Treatment Agreement and requires my signature. Consumer Notice

Medical Doctors are licensed and regulated by the Colorado Board of Medical Examiners (303) 894-7690, or www.dora.state.co.us/medical. Fees for Additional Services (Generally not covered by Insurance).

Forms: Filling out forms is very time consuming and takes Dr. Scott Ross away from scheduled patient care. Therefore, a charge applies for forms that patients request to be filled out by Dr. Scott R. Ross. Examples of such forms include those for DMV, jury duty, disability, etc. Most forms can be completed for a fee of $30.00.

Financial Obligations and Assignment of Benefits

Co-pays and insurance deductibles are due at the time of service for office visits.

As a courtesy, my insurance will be billed by Dr. Scott R. Ross.

I assigned benefits and hereby authorize my insurance carrier to pay Scott R. Ross, D.O., directly for services I require from Dr. Scott R. Ross.

If I receive a check from my insurance for services provided by Scott R. Ross, D.O., I agree to immediately endorse the back of the check to Scott R. Ross, D.O. and send it to: Release of Medical Information to and by Scott R. Ross, D.O.

As a patient, I authorize Scott R. Ross, D.O. (dba “Pain Management of the Rockies, PC.”) to use and/or disclose my health information which specifically identifies me or which can reasonably be used to identifies me to carry out my treatment, payment, and healthcare operations to any person, corporation, or entity including, but not limited to, the Social Security Administrations, Insurance Carriers, Worker’s Compensation carriers, welfare funds, or employers; providing such agents have a financial responsibility concerning my care. This is outlined I the Notice of Privacy Practices.

I understand that I may revoke this consent at any time by notifying Dr. Scott R. Ross, D.O. in Writing, but if I revoke my consent, such revocation will not affect any actions that Scott R. Ross, D.O., took before receiving my revocation.

Signature of patient or representative _____________________________Date of Birth____________ Printed name of patient or representative _____________________________ Date__________________ Relationship to Patient ___________________ revised 08172017

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2222 North Nevada Avenue, Suite 5003, Colorado Springs, CO 80907 Main Number: (719) 471-3372 * Fax (719) 471-3927

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION TO

PAIN MANAGEMENT OF THE ROCKIES, PC.

_______________________________________ ______________________________________ Name of Patient Date of Birth _______________________________________ ______________________________________ Street Address City, State, Zip Code

I hereby authorize the disclosure of my protected health information to Pain Management of the Rockies, PC. as described below:

Information to be released: ____Medical History, Examination Reports _____Surgical Reports ____Treatment or Tests _____Hospital Records including reports ____X-Ray Reports/Films _____Development Disabilities ____Laboratory Reports _____Prescriptions ____HIV Test Results* _____Consultations ____Mental Health _____Allergy Records ____Sexually Transmitted Disease _____Drug Records ____Alcoholism _____Other (Please Specify)________________ * A listing of the statutory exceptions to release of HIV Test results with consent is available. Purpose for Need of Disclosure ______All the request of the individual ______Other (Please Specify)_________________________________________________________________________ I understand that I have the right to:

Receive a Copy of Authorization Revoke This Authorization, except to the extent that the person(s) and or organization(s)

listed above have already made in reference to this authorization. This authorization will remain in effect until the following dates(s): ___________________________ __________________________________________________________ ______________________________________ Signature of Patient (or Legal Representative) Date

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Prescribing Drug Monitoring Program Awareness Form

If a patient is prescribed any controlled substance, your pharmacist puts that

information in a database. The PDMP (Prescription Drug Monitoring Program) may

be queried by authorized individuals who are licensed in the State of Colorado as

Physicians, Pharmacist, and Nurses with prescribing authority, Dentist, Optometrist,

Podiatrists, Veterinarians, Physician Assistants, and Resident Physicians, with

training license who are under the supervision of a licensed Physician.

Each Pharmacy must disclose to patients who are receiving controlled substances

that their prescription information will be loaded in to the PDMP and may be

queried by authorized individuals.

Please sign to indicate you have been made aware of this requirement.

Patient’s Name Printed / Patient Signature Date of Birth Date