well Cornell Medicine

well Cornell Medicine Center for Comprehensive Spine Care Attn: Jude Anthony A Garcia Please note which department or physician you are requesting to see: Phone: (888) 922-2257 (888-WC-BACKS) Please return this form to our office via fax. (646)962-0640 n 'For Eric Bowl% MD; Kai-Ming Fu, MD; and All A. Baal, MD; please return forms to (646) 962-0119 1‘11 • k ART L_ Neurosurgery Neurology Pain Management NEW PATIENT QUESTIONNAIRE Patient Name: C-- re171 Date of Birth: Cl / / I 9 53 Gender: M Phone Number: ddress: 9 GAS? —413r sr, N Y it! local Referred by h Insurance Carrier/ ID or Policy Il i 4t1 I -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: 1. LA h t • 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. RIGHT LEFT LEFT A-. ACHE B= BURNING N= NUMBNESS F.= PINS/NEEDLES S= STABBING 0= OTHER RIGHT Please note if other: I. When did the pain begin? Duration of Pain: Overall the pain is: Improved 2. Quality of Pain Sore Sharp Stabbing Shooting Unsure Worse Stable (Cheek all that applies)? Aching Burning Dull Tender Tingling Cramping Pulling Radiating Throbbing On a scale of 0 to 10, please circle your level of pain or discomfort 0 being none and 10 being unbearable for the following areas: 1. Neck Pain: 0 2. Left Shoulder Pain: 0 3. Right Shoulder Pain: 0 4. Left Arm Pain: 0 5. Right Arm Pain: 0 6. Back Pain: 0 7. Left Hip/Buttock Pain: 0 8. Right Hip/Buttock Pain: 0 9. Left Leg Pain: 10. Right Leg Pain: 11. Left Foot Pain: 12. Right Foot Pain: 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 5 S 5 5 S 5 6 6 6 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 8 8 8 8 8 8 8 8 8 8 8 8 Physiatry/Rehab Medicine DATE: dAhl-1 T lao 9 9 9 9 9 9 9 9 9 9 9 9 If you are not experiencing pain as a symptom, please skip Questions 1-7. 3. What makes the pain better (cheek all that applies)? I lent Cold Bend Forward Bend Back Change Position Sitting Standing Walking Twisting Movement Change in weather Lying Supine Rest Valsalva Coughing/Sneezing Nothing Sex N/A 4. What makes the pain worse (check all that applies)? I leaf Cold Bend Forward Bend Back Change Position Sitting Standing Walking Twisting Movement Change in weather Lying Supine Rest Valsalva Coughing/Sneezing Nothing Sex N/A 1 10 10 10 10 10 10 10 10 10 10 10 10 EFTA00313804 5. Pain interferes with: 7.11pain limits activity, please full in all that apply: Sleep Appetite Sex I can't tolerate walking more than blocks. Self-Care I lobbies Job Performance Driving Social Life Exercise I can't tolerate sitting more than minutes. Lifting household Chores Other Traveling Shopping Cooking I can't tolerate standing more than I can't tolerate lying more than minutes. minutes. 6. When Is the pain worst? (Circle one) Morning Afternoon Evening 8. Do you experience weakness? Yes or No Night If yes, please describe (include location) Have you had any of the following imaging studies? 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/back condition and include the date of treatment: bR if aid Nerve Block Steroid Injections of QCI1 Jtn4C Physical Therapy Acupuncture Chiropractic Other If surgery is recommended, what would be your timeframe available for scheduling? Psychotherapy Surgery Failed Medications REVIEW OF SYSTEM% GENERAL ENDROCRINE NEUROLOGICAL Fatigue o NO o YES 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 PSYCHOLOGICAL Difficulty swallowing o NO a YES 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 Change in bowel habits 0 NO 0 YES Shortness of breath o NO c YES Pass blood from rectum 0 NO 0 YES History of Cancer? Yes No Chest pain or pressure attacks a NO a YES If yes, type: Frequent cough a NO o YES MUSCULOSKELETAL Chemo: Yes No Swollen ankles a NO o YES Decreased Range of Motion a NO o YES Radiation: Yes No Valve disorder o NO a YES Joint Swelling o NO a YES Sleep Apnea o NO o YES Joint Stiffness NO YES Please notify the MD/NP/PA/RN If you are DVT a NO a YES o a Muscle Aches/Pains a NO o YES pregnant: Yes No Stents o NO o YES Other 2 EFTA00313805 Current Medication: Dosage: Frequency: 1. 2. 3. 4. 5. 6. 7. 8. ,octal History: 1. Any allergies to: Shellfish Iodine Latex Contrast/IV dye Allergies Reaction 1. 2. 3. Are you a: Current Smoker / Never Smoker / Former 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 Children Parents Other: 7. What is your occupation? 8. Are you disabled? Yes or No If yes, note disability: 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 patient and the reason that the patient was unable to complete the form. Form Completed by Date 3 EFTA00313806 Weil Camel Medicine Center for Comprehel Spine Care Oswestry Disability Questionnaire This questionnaire has been designed to give us information as to how your back or leg pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply but please just shade out the spot that indicates the statement which most clearly describes your problem. Section 1: Pain Intensity o I have no pain at the moment o The pain is very mild at the moment o The pain is moderate at the moment o The pain is fairly severe at the moment o The pain is very severe at the moment o The pain is the worst imaginable at the moment Section 2: Personal Care (eg. washing, dressing) I can look after myself normally without causing extra pain o I can lock after myself normally but it causes extra pain o It is painful to look after myself and I am slow and careful o I need some help but can manage most of my personal care o I need help every day in most aspects of self-care o I do not get dressed, wash with difficulty and stay in bed Section 3: Lifting o I can lift heavy weights without extra pain c I can lift heavy weights but it gives me extra pain o Pain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed (eg. on a table) o Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned o I can only lift very light weights I cannot lift or carry anything Section 4: Walking* o Pain does not prevent me walking any distance o Pain prevents me from walking more than 1 mile o Pain prevents me from walking more than 'A mile o Pain prevents me from walking more than 100 yards o I can only walk using a cane or crutches o I am in bed most of the time Section 5: Sitting o I can sit in any chair as long as I like o I can only sit in my favorite chair as long as I like o pain prevents me sitting more than one hour o Pain prevents me from sitting more than 30 minutes o Pain prevents me from sitting more than 10 minutes o Pain prevents me from sitting at all Section 6: Standing o I can stand as long as I want without extra pain o I can stand as long as I want but it gives me extra pain o Pain prevents me from standing for more than 1 hour o pain prevents me from standing for more than 30 minutes o Pain prevents me from standing for more than 10 minutes o Pain prevents me from standing at all Section 7: Sleeping o My sleep is never disturbed by pain o My sleep is occasionally disturbed by pain o Because of pain I have less than 6 hours sleep o Because of pain I have less than 4 hours sleep o Because of pain I have less than 2 hours sleep o Pain prevents me from sleeping at all Section 8: Sex Life (if applicable) o My sex life is normal and causes no extra pain 0 My sex life is normal but causes some extra pain o My sex life is nearly normal but is very painful O My sex life is severely restricted by pain o My sex life is nearly absent because of pain c pain prevents any sex life at all Section 9: Social Life o My social life is normal and gives me no 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 limiting my more energetic interests e.g. sport o Pain has restricted my social life and I do not go out as often o Pain has restricted my social life to my home o I have no social life because of pain Section 10: Travelling o I can travel anywhere without pain o I can travel anywhere but it gives me extra pain o Pain is bad but I manage journeys over two hours o Pain restricts me to journeys of less than one hour o Pain restricts me to short necessary journeys under 30 minutes o Pain prevents me from travelling except to receive treatment EFTA00313807 Weil Cornell Medicine Center for Cn Spine Cart- Neck Disability Index This questionnaire has been designed to give us information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only the one box that applies to you. We realize you may consider that two or more statements in any one section relate to you. but please just mark the box that most CJosety describes your problem. Section 1: Pain Intensity o I have no pain at the moment o The pain is very mild at the moment o The pain is moderate at the moment o The pain is fairly severe at the moment o The pain is very severe at the moment o The pain is the worst imaginable at the moment Section 2: Personal Care (Washing, Dressing, etc.) o I can look after myself normally without causing extra pain o I can look after myself normally but it causes extra pain o It is painful to look after myself and I am slow and careful o I need some help but can manage most of my personal care o I need help every day in most aspects of self care o I do not get dressed. I wash with difficulty and stay in bed Section 3: Lifting o I can lift heavy weights without extra pain o I can lift heavy weights but it gives extra pain o Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table o Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned o I can only lift very light weights o I cannot lift or carry anything Section 4: Reading o I can read as much as I want to with no pain in my neck 01 can read as much as I want to with slight pain in my neck o I can read as much as I want with moderate pain in my neck o I can't read as much as I want because of moderate pain in my neck o I can hardly read at all because of severe pain in my neck o I cannot read at all Section 5: Headaches O I have no headaches at all o I have slight headaches. which come infrequently o I have moderate headaches. which come infrequently o I have moderate headaches, which come frequently o I have severe headaches, which come frequently o I have headaches almost all the time Section 6: Concentration I can concentrate fully when I want to with no difficulty o I can concentrate fully when I want to with slight difficulty o I have a fair degree of difficulty in concentrating when I want o I have a lot of difficulty in concentrating when I want o I have a great deal of difficulty in concentrating when I want o I cannot concentrate at all Section 7: Work o I can do as much work as I want to 01 can only do my usual work, but no more o I can do most of my usual work, but no more o I cannot do my usual work o I can hardly do any work at all o I can't do any work at all Section 8: Driving o I can drive my car without any neck pain o I can drive my car as long as I want with slight pain in my neck o I can drive my car as long as I want with moderate pain in my neck o I can't drive my car as long as I want because of moderate pain in my neck o I can hardly drive at all because of severe pain in my neck o I can't drive my car at all Section 9: Sleeping I have no trouble sleeping o My sleep is slightly disturbed (less than 1 hr sleepless) o My sleep is mildly disturbed (1.2 hrs sleepless) o My sleep is moderately disturbed (2-3 hrs sleepless) o My sleep is greatly disturbed (3-5 hrs sleepless) o My sleep is completely disturbed (5-7 hrs sleepless) Section 10: Recreation o I am able to engage in all my recreation activities with no neck pain at all o I am able to engage in all my recreation activities, with some pain in my neck o I am able to engage in most, but not all of my usual recreation activities because of pain in my neck 0 I am able to engage in a few of my usual recreation activities 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 Physicians for your health-care needs. The following is our payment policy which we require you to read and sign prior your visit(s). Patients have many different types of insurance and payment options for services rendered. Also, not all physicians in the practice accept the same type of insurance. To ensure that we have accurate information to process your claim, we will make a copy of your medical insurance and/or Medicare card at the time of your appointment. You are required to inform us immediately of any changes in demographic information or medical insurance information. Patients without medical insurance are required to pay in full at time of service. We understand that financial hardships may affect your ability to pay in full. We will always do everything we can to work with you. Please ask to speak to our Site Manager to discuss a satisfactory arrangement. Participating Plans You must present your insurance card, and if applicable, your insurance referral form, at every visit. We will submit bills directly to your insurance company for payment on your behalf. Patients without insurance cards or proper referrals will be asked for full payment at time of service. All co-pays, deductibles and non-covered services will be collected at time of service. Non-Participating Plans If your provider does not participate in your insurance plan, you are responsible for payment of all charges at the time of service. We can submit the claim directly to your carrier or a claim can be mailed to you. Payment in full is due at the time of service for all non-medically necessary services and/or cosmetic services. Usual and Customary Rates Your insurance policy is a contract between you and your insurance company. Our practice is committed to providing the best treatment for your patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company'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. TALI- p Patient Signature Date )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 participate with your health plan. By signing this document you acknowledge that the provider does not participate in your health plan and therefore this and any other visits or services from this provider may result in costs not covered by your health plan. If you agree to receive healthcare services from this provider, you are entitled to request an estimate of the physician charges for the anticipated services associated with this visit or any planned procedure. Many Weill Cornell Physicians participate in various health plan networks, although not every physician participates in every plan. You can find a list of the plans in which each physician participates by searching their name here: htto://weillcornell.org/ under the tab "insurances". By providing your signature below, you acknowledge that you have agreed to visits with a non- participating provider. Signature of of Patient or Patient's Representative Date EFTA00313810 Weill Cornell Medical College (WCMC) Privacy Office Forms Authorization To Disclose Health Information Via E-Mail Patient Name: -TIE 1-7 1 fa. e c_---ps-ra IN) 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 by Weill Cornell Medical College (WCMC) personnel to a patient or a patients representative through e-mail communication. It expires when the need to communicate via e-mail is no longer necessary, when the patient changes his/her e-mail address. or if the patient revokes S. *teed 64. To be completed by patient or patient's representative: My signature at the bottom of this form is authorization for WCMC to disclose the health information of the above- named patient via e-mail. It also confirms my understanding that: • Information sent via e-mail is not considered secure. There is the possibility of re-disclosure of the personal health Information or the risk that it may be disclosed or seen by an unintended recipient, such as any person who has access to your e-mail account. Re-disclosure may no longer be protected by law. • I should not use e-mail for any urgent or time-sensitive medical questions or issues • Once transmitted, I am responsible for safeguarding the information I receive • I have the right to revoke this authorization at any time before information is disclosed by submitting to the Privacy Office a WCMC Revocation of Release of Medical Information Form 0 PO012S. A revocation vnll not apply to information that has already been released as a result of this authorization • To initiate e-mail communication, I will send an e-mail from my e-mail address. containing my request for information, to the WCMC party at the e-mail address below • I am responsible for notifying the WCMC party listed below if my e-mail address changes and completing another authorization in order to communicate using a different address • If I am communicating via e-mail about someone else. I attest that I am responsible for that persons care or payment and will indicate my relationship to the patient below • WCMC will not condition treatment or payment upon receipt of an authorization • The e-mail address I wish to use is: • jeeVa eciti on ecT O nr, ck nn J 4 IC • PatienVRepresentative Signature Date If the patient listed above is a minor or is unable to sign, and you are a parent. legal guardian, or personal representative who will use e-mail to communicate about this patient, please sign above and complete the following: Print name Relationship to patient To be completed by WCMC: Name of WCMC party (please print): WCMC e-mail: .110••••1111. WCMC. please indicate date completed: . retain a copy of this request in the patients Me. and provide a copy of the original to the requeslor PO0268 Page 1 of I Eff: 111445 FM Auth Email 090115 Rev 1011/07 Rev: 1/15/09 EFTA00313811