Bay Area Pain Medical Associates
(BAPMA)
3 Harbor Drive, Suite 115
Sausalito, CA 94965
415 380 0480 Facsimile 415 380-8788

Initial Intake Form

Your Name:________________________

I. Release and Authorization

BAPMA has informed me their physicians only participate in the Medicare insurance plan. Unless I have Medicare, my medical claims will be processed as “OUT OF NETWORK BENEFITS.” Although BAPMA will bill my insurance as a courtesy, I am responsible for my medical bills.

I authorize BAPMA to release any medical information (may include information related to mental illnesses or conditions, alcohol and/or drug use, HIV status) necessary to my insurance company in order to obtain preauthorization for outpatient visits and as necessary to process my insurance claims.

I authorize and request payment of medical benefits directly to BAPMA. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me in writing.

If my treatment is related to a verified worker’s compensation injury, I understand that I am responsible for any charges for treatment that are unrelated to my worker’s compensation injury and for all charges if the injury is deemed to be non-work related.

I agree that a copy of this form may be used instead of the original.


II. Patient Consent and Acknowledgement of Privacy Practices

For Use and Disclosure of Protected Health Information to
Carry- out Treatment, Payment, and Healthcare Operations


I hereby states that by signing this Consent, I agree and acknowledge the following:

The Practice’s Privacy Notice has been provided to me prior my signing this Consent. The Privacy Notice includes a description of the uses and/or disclosure of my protected health information (“PHI”) necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment and to carry out its normal operations. I understand that the Privacy agreement will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this Consent. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in accordance with applicable law.

I understand that, and consent to, the following appointment reminders that will be used by the Practice:

Telephoning my home and leaving a message on my answering machine or with the individual answering the phone.


I consent to the following persons receiving detailed information (medical reports or verbal communication) regarding my diagnosis and treatment, including test results (e.g. laboratory, x-ray, and procedural results):

  • Name__________________________

  • Name___________________________

  • Name __________________________

The Practice may and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations.

I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operation. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on them.

I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this Consent. I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me.

I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice cannot treat me.


Patient Signature _________________________________ Date_______________


III. Initial Assessment


What are you goals for treatment at Bay Area Pain Medical Associates?

1.

2.

3.




    Yes No

    2) On the diagram shade in the areas where you feel pain. Put an X on the area that hurts the most.




    3) Please rate your pain by circling the one number that best describes your pain at its
    worst in the past 24 hours.

    0 No pain
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10 Pain as bad you can imagine


    4) Please rate your pain by circling the one number that best describes your pain at its
    least in the past 24 hours.


    0 No pain
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10 Pain as bad as you can imagine

    5) Please rate your pain by circling the one number that best describes your pain on the
    average

    0 No pain
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10
    Pain as bad as you can imagine



    6) Please rate your pain by circling the one number that tells how much pain you have
    right now.


    0 No pain
    1
    2
    3
    4
    5
    6
    7
    8
    9
    10 Pain as bad as you can imagine

    7) In the Past 24 hours, how much relief have pain treatments or medications provided? Please circle the one percentage that most shows how much relief you have received

    0%
    No Relief
    10%
    20%
    30%
    40%
    50%
    60%
    70%
    80%
    90%
    100%
    Complete Relief


    8) Circle the one number that describes how, during the past 24 hours, pain has interfered with your:


      0
      Does not interfere
      1
      2
      3
      4
      5
      6
      7
      8
      9
      10 completely interferes




        0
        Does not interfere
        1
        2
        3
        4
        5
        6
        7
        8
        9
        10 completely interferes




          0
          Does not interfere
          1
          2
          3
          4
          5
          6
          7
          8
          9
          10 completely interferes



          D. Normal work (includes both work outside the home and housework

            0
            Does not interfere
            1
            2
            3
            4
            5
            6
            7
            8
            9
            10 completely interferes



            0
            Does not interfere
            1
            2
            3
            4
            5
            6
            7
            8
            9
            10 completely interferes




                0
                Does not interfere
                1
                2
                3
                4
                5
                6
                7
                8
                9
                10 completely interferes



                0
                Does not interfere
                1
                2
                3
                4
                5
                6
                7
                8
                9
                10 completely interferes



                9) Please circle the one word which best describes the duration of your pain

                Occasional
                Intermittent
                Frequent
                Constant


                10) How long ago did your current pain begin _______________

                11) Select the most appropriate word from each category to describe your pain:

                1. Flickering, quivering, pulsing, throbbing, beating, pounding
                2. Jumping, flashing, shooting
                3. pricking, drilling, boring, stabbing, lancinating
                4. sharp, cutting, lacerating
                5. Pinching, pressing, gnawing, cramping, crushing



                12) What treatments (physical therapy, blocks, acupuncture, and surgery) are you receiving? For your pain?

                Treatment
                Description











                13) What medications are you currently receiving for your pain?

                Medication
                Dose











                14) Do you use alcoholic beverages?
                Yes No

                15) If yes,

                Have you ever tried to cut down on your drinking?
                Yes
                No
                Do you get annoyed when people talk about your drinking?
                Yes
                No
                Do you feel guilty about your drinking
                Yes
                No
                Have you ever had an eye opener? (A drink first thing in the morning)
                Yes
                NO


                16) Have you ever received treatment for substance abuse or are you currently being treated?
                Yes No

                17) Do you have any medication allergies? _________________

                18) What medications have tried in the past for your pain?

                Medication
                Dose
                Reason for Stopping Medication
















                19) Past Medical History:
                Please mark an
                X any of the following medical problems you have had:

                Ulcers

                Prostate problems

                Ulcerative colitis

                Hepatitis

                Psoriasis

                Diabetes

                Arthritis (not spine related)

                Heart disease/ Heart attacks

                Tuberculosis

                Stroke

                Cancer

                Asthma

                HIV positive

                Depression

                Seizure

                High blood Pressure

                Kidney problems

                None of these problems


                20) Family History
                Please mark an
                X conditions in your immediate family:
                Cancer

                Back pain

                Arthritis

                Heart Disease/Stroke

                Diabetes

                Bleeding Tendencies

                Depression/ Mental Illness

                Anesthesia difficulties


                21) Review of systems
                Please mark an
                X next to your current systems
                Rashes

                Snoring

                Weight loss

                Psoriasis

                Convulsion/seizure

                Abdominal Pain

                Bruise easily

                Headache

                Nausea/vomiting

                Abnormal lumps

                Dizziness

                Joint swelling

                Painful breast

                Loss of consciousness

                Osteoporosis

                Visual loss

                Palpitations

                Painful urination

                Double vision

                Heart murmur

                Blood in urine

                Sinus problems

                Chest pain

                Kidney Stones

                Breathing problems

                Shortness of breath

                Loss of bladder control

                Sore throat

                Loss of bowel control

                Heart Murmur

                Hoarseness

                Blood in stool

                Shortness of Breath

                Wheezing

                Diarrhea or constipation

                Diabetes



                22) Read each item below and circle the reply that comes closest to how you have been feeling in the past week. Don’t take too long over your replies; your immediate reaction to each item will probably be more accurate than a long, thought-out response.

                I feel tense or ‘wound up’:
                I feel as if I am slowed down
                Most of the time
                Nearly all the time
                A lot of the time from time to time
                Very often
                From time to time, occasionally
                Sometimes
                Not at all
                Not at all


                I still enjoy the things I used to enjoy
                I get a sort of frightened feeling like “butterflies” in the stomach
                Definitely as much
                Not at all
                Not quite so much
                Occasionally
                Only a little
                Quite often
                Hardly at all
                Very often


                I get a sort of frightened feeling as if something awful is about to happen:
                I have lost interest in my appearance
                Very definitely and quite badly
                Definitely
                Yes, but it doesn’t worry me
                I don’t take as much care as I should
                A little, but it doesn’t worry me
                I may not take quite as much care
                Not at all
                I take just as much care as ever


                I can laugh and see the funny side of things:
                I feel restless as I have to be on the move
                As much as I always could
                Very much indeed
                Not quite so much now
                Quite a lot
                Definitely not so much now
                Not very much
                Not at all
                Not at all


                Worrying thoughts go through my mind
                I look forward with enjoyment to things
                A great deal of the time
                As much as I ever did
                A lot of the time
                Rather less than I used to
                From time to time, but not too often
                Definitely less than I used to
                Only occasionally
                Hardly at all


                I feel cheerful:
                I get sudden feelings of panic
                Not at all
                Very often indeed
                Not often
                Quite often
                Sometimes
                Not very often
                Most of the time
                Not at all


                I can sit at ease and feel relaxed
                I can enjoy a good book or radio or TV program
                Definitely
                Often
                Usually
                Sometimes
                Not often
                Not often
                Not at all
                Very Seldom


                IV. Directions
                From the East Bay, take 80 to 580 to the Richmond San Rafael Bridge. Go south on 101 to East Blithdale Exit. Turn right on East Blithdale, then left on Camino Alto. Turn on right on Miller and go to 311 Miller.

                From the South Bay,
                take 280 to 19th Avenue to Park Presidio drive across the Golden Gate Bridge to 101 North. Take the East Blithdale Exit and turn left on East Blithdale, then left on Camino Alto. Turn right on Miller and go to 311 Miller.

                From the North Bay, take 101 South to the East Blithdale Exit. Turn right on East Blithdale, then left on Camino Alto. Turn right on Miller and go to 311 Miller.

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