EFTA00295100.pdf

Back Index 4 ACN Group. Inc Form 81-1C0 •CN &quo. Inc Us* Only no. 3474003 Patient Name Date This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem. Pain Intensity O The pan comes and goes and is very mild. 0 The pan is mid and does not vary much. CD The pain comes and goes and is moderate. co The pain is moderate and does not vary much. O The pain comes and goes and is very severe. The pain is very severe and does not vary much. Sleeping I gel no pain in bed. O I get pain in bed but it does not prevent me from sleeping well. a.) Because of pain my normal sleep is reduced by less than 25% 0 Because of pain my normal sleep is reduced by less than 50%. 0 Because of patn my normal sleep is reduced by less than 75% 00 Pain prevents me from sleeping at at. Sitting • I Can sit in any chair as long as I tike. 0 I can only sit in my favorite chak as long as I like. O Pain prevents me from sitting more than 1 hour. (3) Pain prevents me from sitting more than 1/2 how. OD Pain prevents me from sitting more than 10 minutes. I0 I avoid sitting because it increases pain immediate/ Standing I can stand as long as I want *tout pain. O I have some pain while standing but it does not increase with time. co I cannot stand for longer than 1 hour without increasing pain. CD I cannot stand for longer than 112 hour without increasing pain. (4) I cannot stand for longer itian 10 minutes without increasing pain. O I avoid standing because it increases pain immediately. Walking O I have no pain while waling. 0 I have sane pain while walking but it doesn't increase with distance • I cannot walk more than 1 mile without inaeasng pain. a) I cannot walk more than 1/2 mite without increasing pain. O I cannot walk more than 114 mie without increasing pain. CD I cannot walk at all without increasing pain. Personal Care O I do not have to change my way of washing or dressing in order to avoid pan. 0 I do not normally change my way of wasting or dressaig even though it causes some pain. e Washing and cressag increases the pain but I manage not to change my way of doing it. a) Washing and grassing increases the pain and I find it necessary to change my way of doing it. 0 Because of the pain t am unable to do some washing and dressing without help. e Because of the pain I am unable to do any washing and dressing without help. Lifting O I can lift heavy weights without extra pain. O I can lift heavy weights but it causes extra pain. e Pan prevents me from lifting heavy weights off the floor. (3) Pan prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table). ® Pan prevents me from lifting heavy weights off the ffoor, but I can manage fight to medium weights if they are conveniently positioned. (5), I can only lift very light weights. Traveling O I gel no pain while traveling. O I get some pain while traveling but none a my usual forms of travel make it worse. e I get extra pain while traveling but d does not =se me to seek Nternate forms of travel. a) I get extra pain while traveling which causes me to seek alternate forms of travel. O Pain restricts all forms of travel except that done while lying down. Pan restricts all forms of travel. Social Life • My social fife is normal and gives me no extra pain. i(D My social life is normal but increases the degree of pain. 0 Pin has no significant affect on my social life apart from energetic interests (e.g.. dancing, etc}. 0 Pan has resincted my social the and I do not go out very often. (1) Pin has restricted my social fife to my home. 0 I have hardly any social f e because of the pain. Changing degree of pain O My pain is raactry getting better. 0 My pain euctuates but overall is definitely getting better. e My pain seems to be getting better but improvement is slow. ei My pain is neither getting better or worse. 0 My pain is gradualy worsening. CD My pain is rapidly worsening. kinking my more Back Index Index Score ix (Sum of all statements selected / (# of sections with a statement selected x 5)) x 100, Score EFTA00295100 citil Columbia University Medical Center Physical Therapy Patient Name MRN # When did your symptoms Stan? Briefly describe your symptoms How did your symptoms start? Average pain intensity last 24 hours: Average pain intensity past week: 0 0 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 How often do you experience your symptoms? (please circle one) I - Constantly (76% - 100% of the time) 2 — Frequently (51% - 75% of the time) 3 — Occasionally (26% - 50% of the time) 4 — Intermittently (0% - 25% of the time) How much have your symptoms interfered with your daily activities? (please circle one) 1 — Not at all 2 — A little bit 3 — Moderately 4 — Quite a bit 5 — Extremely How is your condition changing, since care at this facility? (please circle one) N/A — This is the initial visit I — Much worse 2 — Worse 3 — A little worse 4 — No change 5 — A little better 6 — Better 7 — Much better In general, would you say that your overall health right now is... (please circle one) I — Excellent 2 — Very good 3 — Good 4 — Fair 5 — Poor What makes it feel better? What makes it feel worse? Have you had any treatment for this problem? (describe): Please draw your symptoms on the chart. &Xi Pain: (XXXX) Numbness/tingling: (////////0 Muscle Spasm: (7772) Radiating symptoms: (-#-*-*) Please rate your pain on a scale of 0-10. (0=no pain, 10—requires Emergency Room visit): Currently At best, in the last 72 hours At worst, in the last 72 hours Arc you allergic to latex? YES NO Do you have any special equipment? (canes, crutches, walker, exercise equipment) Do you do any regular exercise? If so, describe: t EFTA00295101 CIE? ColumbiaDoctors NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT OF RECEIPT DATE: I acknowledge that I was provided with a copy of the ColumbiaDoctors Notice of Privacy Practices. Patient Name (Print) Patient Signature If completed by a patient's personal representative, please print and sign your name in the space below Personal Representative (Print) Personal Representative's Signature Relationship For ColumbiaDoctors use only Complete this section if this form is not signed and dated by the patient or patient's personal representative. I have made a good faith effort to obtain a written acknowledgement of receipt of ColumbiaDoctors Notice of Privacy Practices but was unable to for the following reason: o Patient refused to sign o Patient unable to sign o Other Employee Name Date This form should be placed in the patient's medical record Revised March 2014 EFTA00295102 CAP ColumbiaDoctors I Neurological Surgery Patient Name: Unit #: Drug name Dosage Family History Illness - Yes Relative Illness Yes Relative diabetes drinking stroke breast cancer heart disease colon cancer high blood pressure ovarian carter aneurysm other Social History Habits smoking yes no no no packs per day years alcohol yes drinks per day years drug use yes Personal Profile marital status: married occupation: single widowed divorced number of children education: other: Signature of patient: Date: Date reviewed by patient: Physician signature: Date: clip COLUMBIA UNIVERSITY MEDICAL CENTER 4 NewYork-Presbyterian EFTA00295103 di? ColumbiaDoctors I Neurological Surgery Patient Name: Unit N: bruises, frequent enlarged lymph nodes Condone to page 3 Allereidhomunoloeie I Yes No Notes allergies drugs, other Skin " new rashes/skin lesions Other Personal History Operations/ Hospitalizations Reason Date Reason Date Injuries/Illnesses Type Date Current Medications Drug name Dosage cit COLUMBIA UNIVERSITY MEDICAL CENTER -I NewYork-Presbyterian EFTA00295104 Cik? ColumbiaDoctors I Neurological Surgery Patient Name: Unit #: Continue to.lage 2 Gastrointestinal Yes No Notes severe abdominal pain diarrhea bloody stool nausea/vomiting constipation Genitourinary blood in urine painful urination urgency/frequency incomplete emptying painful intercourse For Females abnormal periods last menstrual cycle I Mos culoskeletal/Ntorolovicd muscle weakness trouble walking swelling stroke or seizures head, neck, or back injuries chronic pain "pins and needles" feeling loss of sensation/numbness headaches diriness Psychiatric depression/anxiety psychiatric disorder sleep problems Entszincaitcnal dry skin abnormal thirst hot flashes diabetes adrenal or thyroid disease kidney disease/failure hepatitis/jaundice/cirrhosis Likaasiggisilaamkgs anemia/low blood count bleeding ulcers sickle cell disease GID COLUMBIA UNIVERSITY MEDICAL CENTER 2 NewYork-Presbyterian EFTA00295105 ColumbiaDoctors I Neurological Surgery Patient Name: Unit H: Review of Systems Please check (x) if any of the following apply to you now, in the past, or often. Yes I No I Notes Cu rre nt weight: Height: weight loss/weight gain fever fatigue I Ern double vision spots before eyes vision changes dry eyes glaucoma/cataracts i Etelatth ear aches ringing in ears sinus problems sore throat mouth sores dental problems difficuky swallowing Carditwasrulat painful breathing chest pain or shortness of breath atrial as-illation or irregular heartbeat Swelling of legs high cholesterol high blood pressure heart murmur/heart failure heart attack or angina RIaaraIREY shortness of breath/ swollen ankles wheeimg/cough spitting up blood tuberculosis (tb) smoked in the last year clip COLUMBIA UNIVERSITY MEDICAL CENTER NewYork-Presbyterian EFTA00295106 M.D. Neurosurgical Associates, P.C. 710 West 168th Street New York, NY 10032 UNIT # THE SPINE HOSPITAL az Me leatOLCOCAL wmuw s Yr• Ton 3 MARKETING PATIENT SURVEY Please take the time to 611 out the following information, so we may better serve you and Mute patients. All information will be kept ationynious. Patient Name: (not required) Your Doctor: I. Who was your source of referral or how did you find out about us? Please select all that apply and indicate below. o Family/Fricnd: a Physician: o Print Media: • Website/Search engine: a Social Media: o Other: 2. Did you visit our website (wsvw.columbiancurosurgery ors)? If so, which pagc(s) or video(s) were helpful? o Doctor's Bio Page a Medical Conditions and Treatments Page o Specialties Page o Doctor's Video o Patient Testimonial Video o Blog o Other 3. Did you visit a patient review site (i.e. Ilea Ithgrades.com) about our doctor before you came in? o Yes • If yes, which patient review website(s) did you visit? o Hcalthgrades.com K Vitals.com o RateMds.com o Other: o No 4. Would it be ok for a representative from the marketing department to contact you for your opinion or feedback? o Yes o Texts: ( ) o Emails: o No EFTA00295107 , M.D. Neurosurgical Associates, P.C. 710 West 168th Street New York, NY 10032 UNIT # THE SPINE HOSPITAL AT ME atuaaraarx ttlnnnr CO lift TOM 2 PATIENT FINANCIAL OBLIGATION AGREEMENT I understand that all applicable copayments and deductibles are due at the time of services. I agree to be financially responsible and make full payment for all charges not covered by my insurance company. I authorize my insurance benefits to be paid directly to Neurosurgical Associates, P.C. for services rendered. I authorize representatives of Neurosurgical Associates/Columbia University Medical Center to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim. If my current policy prohibits direct payment to the doctor, I will forward the check and explanation of benefits to Neurological Associates. Patient Signature: Date: / / Guarantor Signature: Date: / / I am aware that , M.D. does not participate with my Commercial Insurance and is an Out-of-Network Provider. Patient Signature: Date: / / MYCOLUMBIADOCTORS PATIENT PORTAL SIGN UP - Access your personal records securely, 24/7, on a computer, smartphone, or iPad. o YES, Send me an invitation to join myColumbiaDoctors. Email: o NO, do not send me an invitation to join myColumbiaDoctors. Look for an email invite from noreply@follownsyhealth.org and click the registration link. Patient's Preferred Language o I decline to respond. Patient Signature: Date: / EFTA00295108 , M.D. Neurosurgical Associates, P.C. 710 West 168 Street New York, NY 10032 PATIENT INFORMATION Date: Patient Name: (Lau Nsmc) (First Nave) (Middle Whale Date of Birth: / / Sex:OM oF Address: City: State: Zip: Home ( ) Cell lk ( Email: Father's First Name: Mother's First Name: Employer's Name: Occupation: Wm* 4: ( _) Fax #:( ) Spouse Name: (Last Name) (Fine Nast) Date of Birth: / / Cell #: ( ) Email: If different than patient:. Guarantor's Name: (tats Newel (Fins Name) Date of Birth: / / Sex: o MI Cell #: ( ) UNIT # THE SPINE HOSPITAL At Mt 4010104CAL atnivri oi ara mu 1 INSURANCE Primary Insurance: Policy II: Group #: Phone ( Secondary Insurance: Policy II: Group #: Phone #: ( Check if apply and answer the following questions: a Workers Compensation a Auto Accident/NoFault Date of Accident: / / Carrier Name: Representative Name: State of Accident: Policy #: Address: Phone th ( ) REFERRING PHYSICIAN Referring Physician Name: Address: Phone #: ( ) - Primary Care Physician Name: Address: Phone tl: ( ) - Pharmacy Name: Address: __ Phone #: ( 1 - EFTA00295109 (it ColumbiaDoctors Patient Request for Unencrvoted Email Communication Patient Name: Date of Birth: Phone Number: Email Address: This form authorizes your provider/program to communicate with you via unencrypted email. I understand that communications over the Internet or use of an email system may not be secure and there is no assurance of confidentiality when communicating via unencrypted email. Please be advised that: • This request applies only to the healthcare provider or program stated below. A separate form is required if you would like to request to communicate via unencrypted email with another health care provider or program. • An email address must be provided - A test email is recommended before corresponding via email. I understand and agree to the following: - The email address provided is accurate and I accept responsibility for messages sent to or from this email address. I have received a copy of the IMPORTANT INFORMATION ABOUT PATIENT EMAIL form. Communication over the internet or using unencrypted email may not be secure and there is no assurance of confidentiality of information communicated via unencrypted email. Email communications may be forwarded to other providers and documented in my medical record for my treatment. I have the right at any time to revoke this authorization by contacting my provider and informing them that I wish to revoked my authorization. I agree to hold ColumbiaDoctors and individuals associated with ColumbiaDoctors harmless from any and all claims and liabilities arising from or related to this request to communicate via unencrypted email. Signature of patient Date Name of Physician or Program Updated July 2017 EFTA00295110 Columbia University Medical Center THE SPINE CENTER at The Neurological Institute 710 West 168° Street, 561 Floor Ncw York, NY 10032 Telephone: (212) 305-9625 Fax: (212) 342.1540 We are looking forward to working with you! For your first appointment, please: • Arrive 15 minutes prior your appointment time • For low back treatment: please bring you loose clothing and sneakers. example: (shorts, sweat pants, t-shirt) • For neck treatment: please bring t-shirt or tank top For your insurance coverage please bring: • All of your insurance cards • A physical therapy prescription that is filled out, dated and signed by your doctor every 3 months • A filled-out physical therapy "pre-authorization form" with your primary care physician's signature and telephone number on it, if this is required by your insurance company **Notice of Advise • At the time of your Physical Therapy visit, if you do not have a referral from you physician or nurse practitioner your treatment may not be covered by your health plan. It is your (patients) responsibility to obtain all referrals if required by your health insurance policy up to date. Policy for ALL your therapy appointments: • We urge you to keep all of your scheduled therapy sessions and to be on time. If you miss appointments: • If you miss 2 or more appointments, your therapy sessions may be cancelled. If you are late for an appointment: • If you arc 10 or more minutes late, you session may either be shortened or rescheduled. Please be on time for all appointments because other patients are scheduled after you. If you need to cancel or change an appointment: • If you must cancel or change you appointment, please call us at least 24 hours before your scheduled appointment at 212-305-9625. This will give us enough time to give your time slot to someone else. I have read the physical therapy policies and understand them. ••Assienment of Benefits for Physical Theraov: I hereby authorize assignment of payment directly to Neurosurgical Associate, PC at The Spine Center. If my current policy prohibits direct payment to the providers, I will forward a check to the above address. understand that I am financially responsible for charges that arc not covered by my insurance I understand that if I do not have a referral from a physician, podiatrist, or nurse practitioner, there is a possibility that treatment may not be covered by my health care plan insurer and that my treatment by be a covered expense if rendered pursuant to such referral. / am fully aware that I am fully responsible for fees denied or not covered by my insurance. Patient Signature/Guardian Signature Date Thank you very much. We appreciate your cooperation. EFTA00295111