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44 Route 23 North, Suite 15B

Riverdale, NJ 07457 Phone: (973) 400 -1716 Fax: (973) 400-1631

New Patient Demographics Form Last Name __________________________ First _______________________Middle______________________ Address ______________________________ City ____________________State _________ Zip ____________ Home telephone ( ) ________________Date of Birth ____________Sex _____ Age __________ Work telephone ( ) ______________________ Cell telephone ( ) ________________ Social Security # ________________________ Martial Status_________________________ Spouse’s Name _____________________________________ Emergency Contact Name __________________________________ Relationship _____________________________ Telephone # ( ) ___________________ Address ______________________________ City ______________________State ________ Zip ___________ Employer Information

[ ] Currently employed [ ] Unemployed [ ] Retired [ ] Legally disabled Company Name _________________________ Address ______________________________City _______________________State ________ Zip ____________ Work telephone ( ) ______________________ Cell telephone ( ) ________________ Primary Care Physician

Name __________________________________________________Telephone # ( ) ______________________ Address ______________________________City _______________________ State ________Zip _____________ Referring Physician Name __________________________________________________Telephone # ( ) ______________________ Address ______________________________City _______________________ State ________Zip _____________

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Primary Insurance Insurance Company ____________________________Cardholder’s Name ______________________________ Policy # ______________________________________ Group # _______________________________________ Cardholder’s date of Birth ____________________________ Cardholder’s social Security Number ______________________________ Secondary Insurance Insurance Company _____________________________Cardholder’s Name _______________________________ Policy # _______________________________________ Group # ________________________________________ Cardholder’s date of Birth ____________________________ Cardholder’s social Security Number ______________________________ Worker’s Compensation Information Date of Injury ____________________ Claim # _____________________ Ins. Carrier _______________________ Address _____________________________ City ______________________State __________ Zip _____________ Telephone # ( __ ) __________________ Adjuster ___________________________________________________ Employer at time of injury _________________________________________ Motor Vehicle Accident (PIP) Information Date of Accident____________________ Claim # _____________________ Ins. Carrier _______________________ Address _____________________________ City ______________________State __________ Zip _____________ Telephone # ( __ ) __________________ Adjuster ___________________________________________________ Signature ___________________________________________ Date _______________________

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44 Route 23 North, Suite 15B

Riverdale, NJ 07457 Phone: (973) 400-1716 Fax: (973) 400-1631

Comprehensive Pain Questionnaire

Last Name ___________________ First __________________ Middle Initial ________ Date of Birth __________________ Age _______ Weight _________________ Height ___________ Chief Complaint What is the main problem for which you are seeking treatment at New Jersey Pain Care Center? ________________________________________________________________________________________________________________________________________________________ ONSET OF PAIN How did your current pain start? Injury at work Treatment caused (e.g., radiation, surgery, etc.) Injury, not at work Motor vehicle accident Illness, non-injury Undetermined Other_____________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ DURATION How long have you had your current pain problem? _____ Years _____ Months PRIOR CONSUATIONS Which physicians have you seen for your current condition? Primary Care Physician_____________________ Neurosurgeon_____________ Neurologist _____________________ Physiatrist________________ Orthopedic surgeon_________________ Other____________________

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DIAGNOSTIC STUDIES What diagnostic studies have you had? MRI:

a. Back Date:________ b. Neck Date:________

CT scan: a. Back Date:________ b. Neck Date:________

EMG Date:________ X-rays Date:________ Other___________________ Date:________

PAIN LOCATION Please describe the location(s) of you pain: ____________________________________________________________________________

Please mark the location(s) of your pain on the diagrams above. If whole areas are painful, please shade in the painful area. RATE YOUR PAIN

(0-10 scale where 0 is no pain and a 10 is the worst possible pain) I would rate my pain today a _____/10 I would rate my worst pain a _____/10. I would rate my pain when under control as a _____/10. I could accept or live with a level of pain at a _____/10.

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PAIN QUALITY How would you describe the pain?

Burning Sharp Cutting Throbbing Cramping Numbness Dull Aching Pressure Soreness Pins and needles Shooting Other______________

In general, during the past month when has your pain been (please check one)?

Worsening Improving Unchanged TIMING OF PAIN How often do you have your pain? (Please check one)

Constantly (100% of the time) Nearly constantly (60% to 95% of the time) Intermittently (30% to 60% of the time) Occasionally (less than 30% of the time)

ACTIVITIES AND YOUR PAIN During the past month, check the activities that you avoided because of pain:

Going to work Performing household chores Doing yard work or shopping Socializing with friends Participating in recreation Having sexual relations Physically exercising

Does your pain cause any of the following?

Loss of bowl control Loss of bladder control Loss of sleep How many blocks can you walk before having to stop secondarily to pain?

Less than a block ________blocks How many minutes or hours can you sit before having to get up and move about? _________Hours ________Minutes How many minutes or hours can you stand before you have to sit down? _________Hours ________Minutes How often during the day do you lie down because of pain?

Never Seldom Sometimes Often Constantly

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RELIEVING AND AGGREVATING FACTORS How do the following affect your pain? (Please check one for each item) Decrease No Change Increase Lying down 0 Standing Sitting Walking Exercise (if applicable) Medications Relaxation Thinking about something else Coughing/Sneezing Urination Bowel movements PAIN TREATMENTS Please check all of the treatments you have tried for your pain and then complete the appropriate column at the right to the best of your ability.

Treatment

Date (approximate)

No Relief

Moderate Relief

Excellent Relief

Hospital bed rest

Traction

Surgery

Hypnosis

Acupuncture

Nerve block or injections

TENS

Physical therapy

Exercise

Biofeedback

Psychotherapy

Chiropractic

Other

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PRIOR MEDICAL HISTORY Have you had any of the following health problems? (Please check all that apply)

High blood pressure Diabetes or high blood sugar Kidney disease Angina or chest pain Heart attack Liver disease Asthma or wheezing Chronic cough Arthritis (TIA) or stroke Seizure or epilepsy Bleeding problem Cancer; please specify what type_______________________________ Other; please specify ______________________________________________________

__________________________________________________________________________ __________________________________________________________________________ PAST SURGICAL HISTORY

Date (approximate)

Hospital Type of Operation

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FAMILY HISTORY Mother Father Siblings Other REVIEW OF SYSTEMS Constitutional Cardiovascular Gastrointestinal Neurological

Weight change Heart trouble Nausea Frequent headaches Loss of appetite Chest pain Diarrhea Light headed or dizzy Fatigue Heart murmur Constipation Convulsions or seizures Insomnia Palpitations Abdominal pain Numbness or tingling Fever Varicose veins Blood in the stool Tremors

Swelling of the feet or ankles Paralysis Head injury Memory loss Fainting Poor balance Eyes Genitourinary Respiratory

Eye disease Frequent urination Shortness of breath Glasses or contacts Urgency of urination Chronic cough Blurred or double vision Painful urination Wheezing Vision loss Incontinence

Sexual difficulty Kidney stones Ears/Nose/Mouth/Throat Hematological Psychiatric

Hearing loss Bleeding tendency Nervousness Ringing in the ears Anemia Depression Sinus problems Recurrent infections Hallucination Nose bleeds Mouth sores Swollen glands in the neck

Musculoskeletal Endocrine Skin

Joint pain Excessive thirst Rash or itching Joint swelling Heat or cold intolerance Change in skin color Weakness of muscles or joints Glandular or hormone problems Change in hair or nails Muscle pain or cramps Back pain Difficulty walking

_____________________________________________________________________________________

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MEDICATIONS Indicate the prescription medications you currently taking by checking the box. Please tell us the dosage (if known) and number of pills you take (on average) of this medication. Write this in the space next to the name of the medication. If you can remember, draw a line through the name of any medications that you have tried in the past but are no longer taking.

Actiq Mobic Adapin (Doxepin) Morphine Amrix MS Contin Anaprox (Naproxen) Naprelan Anexsia (Hydrocodone) Naprosyn Ativan Norco (Hydrocodone) Avinza Norflex Axert Norpramin (Desipramine) Baclofen (Lioresal) Opana (IR/ER) Buprenorphine Oxycodone BuSpar Oxycontin Celebrex Pamelor (Nortriptyline) Codeine Percocet (Oxycodone) Cymbalta Percodan (Oxycodone) Darvocet Provigil Darvon Prozac Desyrel (Trazodone) Restoril Dilaudid Ritalin Elavil (Amitriptyline) Robaxin Empirin with codeine Roxicodone Endocet Sinequan (Doxepin) Feldene Skelaxin Fentanyl Soma Fiorinal Tegretol Fiorinal with codeine Tofranil (Imipramine Flexeril Topamax Frova Toradol Halcion Tylenol with codeine Ibuprofen (Motrin) (Advil) Tylox Imitrex (Sumatriptan) Valium Indocin Vicodin Kadian Ultracet Klonopin (Clonazepam) Ultram (Tramadol) Lexapro Ultram ER Lidoderm 5% Xanax (Alprazolam) Limbrel Zanaflex (Tizanidine) Lioresal _____________ Lortab _____________ Lyrica _____________ (Hydrocodone) _____________ Methadone _____________

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ALLERGIES I am allergic to dye (Contrast) Please indicate the names of any medications that you are allergic to in the space below EDUCATION Your highest educational level achieved:

Graduate or professional training (obtained degree) College graduate (obtained degree) Partial college training High school graduate GED or trade-technical school graduate Partial high school (10th grade through partial 12th) Partial junior high school (7th grade through 9th grade) Elementary school (6th grade or less)

EMPLOYMENT Your current or former occupation:

Skilled trade or clerical (e.g., carpenter, electrician, truck driver, secretary) Semi-skilled or unskilled (e.g., dishwasher, porter, assembler) Business executive or managerial Professional (e.g., lawyer, teacher, nurse, physician, psychologist) Homemaker Other

Current employment status (please check all that apply):

Employed full-time Employed part-time Unemployed Homemaker Retired Student Unemployed because of pain Part-time because of pain

If you are currently unemployed, indicate how long you have been off work: (If employed, do not answer)

1 - 3 weeks 8 - 11 months 25 or more months 1 - 3 months 12 - 18 months 4 - 7 months 19 - 24 months

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LEGAL ISSUES Please indicate any of the following claims you have filed related to your pain problem

Workers' compensation Personal injury/liability (unrelated to work) Social Security Disability Insurance (SSDI) Other insurance None

ATTORNEY’S NAME & CONTACT INFORMATION _____________________________________________________________________ SOCIAL Alcohol use Yes No _____________/Week? Tobacco use Yes No _____________/packs per day Recreational drug use Yes No ________________________ Marital status Single Married Separated Divorced Widow Living arrangements Living alone Living with friends Living with children Living with spouse/partner Living with other PSYCHOLOGICAL TREATMENT Have you ever had psychiatric, psychological, or social work evaluations or treatments for any problem, including your current pain? Yes No If yes, when? Have you ever considered suicide? Yes No If yes, when? SUBSTANCE ABUSE Do you have a history of alcoholism? Yes No Heroin abuse? Yes No Cocaine abuse? Yes No Have you ever been in a detoxification program for drug abuse? Yes No Alcoholics Anonymous? Yes No

Patient Agreement Form

Thank you for selecting New Jersey Pain Care Center. In order to facilitate your treatment here we ask that you read and sign this agreement and authorization. If you have any questions, please do not hesitate to ask for clarification.

∙ Fees due to New Jersey Pain Care Center, PC for: Patient co-payment(s), deductible(s), cancellation fees, and treatments or fees not covered by a pre-approved medical insurance plan are to be paid prior to treatment. ∙ We will bill your insurance carrier as a convenience to you, however, if your carrier reimburses you, you agree to inform us of the receipt and to pay us promptly. ∙ If your care is not covered by insurance, you agree to be responsible for payment of all fees in full. ∙ You understand that, as a patient of New Jersey Pain Care Center, PC you must cancel your appointments at least 24 hours prior to the appointment. Failure to cancel the appointment in a timely manner will result in a $50 late cancellation fee. ∙ You understand that, as a patient of New Jersey Pain Care Center, PC will have 30 days prior to your account in full after your insurance claim has been adjudicated. Failure to do so will result in your account balance incurring interest in the amount of 1.5% per month until your account is paid in full. ∙ Self-pay patients will have 30 days to pay their account in full. Failure to do so will result in their account balance incurring interest in the amount of 1.5% per month until their account is paid in full.

I, the undersigned understand and agree to the above. ________________________________________________________________________________________________________ Signature of Patient or Authorized Representative Relationship Date

ASSIGNMENT OF BENEFITS

I hereby assign, transfer, and set over to New Jersey Pain Care Center, PC and the Physician responsible for my treatment sufficient monies and/or benefits to which I may be entitled from government agencies, insurance carriers, or others who are financially liable for my medical care to cover the costs of the care and treatment rendered to myself or my dependent. I understand that I am financially responsible for the charges not covered by my insurance. A Photostatted copy of this authorization shall be considered as effective and valid as the original. When signed by a Medicare recipient, this is a lifetime care authorization. Either by the above named carrier or myself may revoke this authorization at any time in writing.

___________________________________________ Insurance Company

_____________________________________________________________________________________________ Signature of Patient or Authorized Representative Relationship Date

CONSENT FOR MEDICAL TREATMENT

I hereby authorize and request New Jersey Pain Care Center, PC to provide such medical care and administer such diagnostic and/or therapeutic procedures and treatments as in the judgment of the physician in attendance are deemed necessary and advisable. ________________________________________ Insurance Company ___________________________________________________________________________________________________ Signature of Patient or Authorized Representative Relationship Date

AUTHORIZATION FOR RELEASE OF INFORMATION FOR INSURANCE BENEFITS

I hereby authorize and direct New Jersey Pain Care Center, PC, having treated me, to release to government agencies, insurance carriers, or others, who are financially liable for my care, all information need to substantiate payment for my care and to permit representatives thereof to examine and make copies of all records relating to such care and treatment. _________________________________________ Insurance Company ___________________________________________________________________________________________________ Signature of Patient or Authorized Representative Relationship Date

I understand that I am entering into a contractual relationship with New Jersey Pain Care Center, PC and the Physician for the professional care. I further understand that merit less and frivolous claims for medical malpractice have an adverse effect upon the cost of availability of medical care, and may result in irreparable harm to medical provider. As additional consideration for professional care provided to me by New Jersey Pain Care Center, PC and the Physician, I and/or my representative agree not to advance, directly or indirectly, any false, merit less, and/or frivolous claim(s) of medical malpractice against New Jersey Pain Care Center, PC and the Physician. Furthermore, should a meritorious medical malpractice case or cause of action be initiated or pursued, I and/or my representative agree to use ABMS board-certified expert medical witness(es) in the same or similar specialty as the Physician. Furthermore, I agree that these expert witnesses will adhere to the guidelines and/or code of conduct defined by the specialty society(ies) for expert witnesses in the area(s) of medicine that would typically have the background and experience to opine on such a case. Finally, you (the patient) agree that counsel for the Physician shall have the right to be free to depose such expert witnesses at least 120 days before any scheduled trial date. In consideration for this, (the Physician) agree to the same stipulations. _______________________________________ _______________________________________ Physician Patient

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

NOTICE OF PRIVACY PRACTICES PURSUANT TO 45 C.F.R. S 164.520

1. Our Duties

We are required by law to maintain the privacy of your Protected Health Information (“Protected Health Information”). We must also provide you with notice of our legal duties and privacy practices with respect to Protected Health Information. We are required to abide by the terms of our Notice of Privacy Practices currently in effect. However, we reserve the right to change our privacy practices in regard to Protected Health Information and make new privacy policies effective for all Protected Health Information that we maintain. We will provide you with a copy of any current privacy policy upon your written request, addressed to our Privacy Officer, at our current address.

2. Your Complaints

You may complain to us and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. You may file a complaint with us by sending a certified letter addressed to “Privacy Officer” at our current address, stating what Protected Health Information you believe has been used or disclosed improperly. You will not be retaliated against for making a complaint. For further information you may contact our Privacy Officer, at telephone number (973) 400-1716.

3. Description and Examples of Uses and Disclosures of Protected Health Information

Here are some examples of how we may use or disclose your Protected Health Information. In connection with treatment, we will, for example, allow a physician associated with us to use your medical history, symptoms, injuries or diseases to treat your current condition. In connection with payment, we will, for example, send your Protected Health Information to your insurer or to a federal program, such as Medicare, that pays for your treatment. This allows us to obtain payment for the services we rendered on your behalf. In connection with health care operations, we will, for example, allow our auditors, consultants, or attorneys access to your Protected Health Information to determine if we billed you accurately for the services we provided to you.

4. Uses and Disclosures Which Require Your Written Authorization

Uses and disclosures other than those involving treatment, payment, and health care operations, as well as those described in the following sections of this Notice, will only be made by obtaining a written authorization from you. You may revoke this authorization in writing at any time, except to the extent that we have taken action in reliance upon your authorization.

5. Uses and Disclosures Not Requiring Your Written Authorization

The privacy regulations give us the right to use and disclose your Protected Health Information if: (I) you are an inmate in a correctional institution; (ii) we have a direct or indirect treatment relationship with you, (iii) we are so required or authorized by law. The purposes for which we

might use your Protected Health Information would be to carry out treatment, payment, and health care operations similar to those described in Paragraph 1.

6. Uses of Protected Health Information to Contact You

We may use your Protected Health Information to contact you regarding appointment reminders or to contact you with information about treatment alternatives or other health-related benefits and services that, in our opinion, may be of interest to you. We may use your Protected Health Information to contact you in an effort to raise funds for our operations.

7. Disclosures of Protected Health Information for Billing Purposes

We may disclose your billing information to any person that calls our billing staff or agents with billing questions after we verify the identity of the person by requesting information such as your social security number or health plan number.

8. Disclosures for Directory and Notification Purposes

If you are incapacitated or not present at the time, we may disclose your Protected Health Information (a) for use in a facility directory, (b) to notify family or other appropriate persons of your location or condition, and (c) to inform family, friends or caregivers of information relevant to their involvement in your care or payment for your treatment. If you are present and not incapacitated, we will make the above disclosures, as well as disclose any other information to anyone you have identified, only upon your signed consent, your verbal agreement, or the reasonable belief that you would not object to such disclosure(s).

9. Individual Rights

(i) You may request us to restrict the uses and disclosures of your Protected Health Information, but we do not have to agree to your request. (ii) You have the right to request that we communicate with you regarding your Protected Health Information in a confidential manner or pursuant to an alternative means, such as by a sealed envelope rather than a postcard, or by communicating to a specific phone number, or by sending mail to a specific address. We are required to accommodate all reasonable requests in this regard. (iii) You have the right to request that you be allowed to inspect and copy your Protected Health Information as long as it is kept as a designated record set, and as long as you pay in advance for the administrative time and costs to make arrangements to have the records inspected and copied. Certain records are exempt from inspection and cannot be inspected or copied, so each request will be reviewed in accordance with the standards published in 45 C.F.R. S 164.524. (iv) You have the right to amend your Protected Health Information for as long as the Protected Health Information is maintained in the designated record set. We may deny your request for an amendment if the Protected Health Information was not created by us, or is not part of the designated record set, or would not be available for inspection as described under section 45 C.F.R. S 164.524, or if the Protected Health Information is already accurate and complete without regard to the amendment. (v) You have the right to request, and thereafter receive, an accounting of the disclosures of your Protected Health Information for six years before the date on which you request the accounting. An exception to this accounting are those disclosures not allowed by law pursuant to section 164.528. Each request for an accounting will be reviewed pursuant to the rules of section 164.528. (vi) You also have a right to receive a copy of this Notice upon request.

10. Effective Date

The effective date of this Notice is April 14, 2009.

I acknowledge receipt of

New Jersey Pain Care Center’s PC Notice of Privacy Practices

Signature: _________________________________________ Date: ___________________________

______________________________________________________________________________________________________________ Patient Name: __________________________________ DOB: ________________ SSN: _________________________________ Address: __________________________________________ City/State/Zip: _______________________________________________ Telephone: ________________________________________ Alternate Contact Number: _____________________________________

Please release the following information: ____ Problem List ____ X-ray Reports ____ Mental Health ____ Outside Records ____ Progress Notes ____ X-ray Films ____ Drug/Alcohol ____ Immunizations ____ History & Physical Exam ____ EKG Reports ____ Lab Reports ____ HIV/AIDS Test ____ Medications Other Reports (Specify) __________________________________________________________ This information is necessary for the following purpose: ____ Continued Patient Care ____ Personal Use ____ Attorney/Legal ____ Insurance ____ (Other (Specify) ____________________________________________________________________________________________ 1. I understand that the information in my health record may include information relating to sexually transmitted diseases, acquired

immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol/drug abuse.

2. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so

in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insure

___________________________________________________________ ______________________________________

___________________________________________________________ ______________________________________

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New Jersey Pain Care Center, PC

44 Route 23 North, Suite 15BRiverdale, NJ 07457

Phone: (973) 400 -1716 Fax: (973) 400-1631Text

In accordance with state law and regulatory agency requirements, the health record is the property of New Jersey Pain Care Center, PC

Authorization for Release and Disclosure of Protected Health Information

3. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this in order to assure treatment. I understand that with certain exceptions, I may inspect or copy the information to be used or disclosed. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have any questions about disclosure of my health information, I can contact the Health Information Management Manager at (973) 400-1716

Signature of Patient or Legal Representative Date

Relationship to Patient Witness

Information May Be Released To:

Name: ____________________________________________

Address: __________________________________________

Phone: (____) ______________________________________