Home » Forms » New Patient Packet New patient history form New patient history form Patient Name * DOB * Allergies to Medicines: Current Medications Name Start Date Dose Times/Days Taken Add Remove Social History Married Single Widowed Divorced Number of Pregnancies * Live Births Occupation Highest Level of Education Drug Use Y/N, if yes * Alcohol Consumption (avg # drinks/week) * Tobacco Use (packs per week/day) * Medical History Please check off all applicable personal medical diagnoses received by a doctor High blood pressure Heart Attack Diabetes Thyroid disease Kidney problems COPD Acid Reflux Stomach ulcers Asthma Liver Disease (specify) Kidney Disease (specify) Cancer specify (type/year diagnosed) Gastric/Colon disease (specify) Please Specify Autoimmune Disease (Lupus/RA/Sjogrens/Vasculitis) Frequent Infections (please specify) Other Surgical History (please list surgeries and dates) Surgery * Add Remove Family History (please list age and health conditions) Mother - Alive/Deceased * Father - Alive/Deceased * Siblings - Alive/Deceased * Relation * Condition * Add Remove Have you been under the care of another Rheumaologist in the past? Yes No Name Number Last time seen: I verify that this information is both complete and accuratePatient Signature * Clear Date TELEPHONE COMMUNICATION PREFERENCE Home CAN WE CALL HERE? Yes No CAN WE LEAVE A MESSAGE? Yes No Work CAN WE CALL HERE? Yes No CAN WE LEAVE A MESSAGE? Yes No Mobile Phone CAN WE CALL HERE? Yes No CAN WE LEAVE A MESSAGE? Yes No Other CAN WE CALL HERE? Yes No CAN WE LEAVE A MESSAGE? Yes No Mail/Email So that we may better serve you, please provide the following pharmacy information: Pharmacy name: * Pharmacy Address * Pharmacy Address Pharmacy Address Pharmacy Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Patient Registration Advanced Rheumatology of Houston 10857 Kuykendahl Rd Suit 120 The Woodlands, TX 77382 Office: (281) 766-7886 Fax: 281-719-9320 () No change in address, phone number Name Last First Middle Date Of Birth Phone Race Black Hispanic Native American Oriental Asian White Chinese Filipino Native Hawaiian Multiracial Pacific Islander Japanese Language Employment Status: Full-time Part-time Self-employed Retired Student Child Unemployed OtherOther Responsible Party (Party Responsible for payment): Self Spouse Parent OtherOther Name Last First Middle Address Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Phone Work Fax Email Primary Insurance: * Insured Party: Self Spouse Parent Other Insured Party: Group # ID Add Remove Acknowledgment of Financial ResponsibilityThis office does not accept responsibility for collection you insurance proceeds or for the negotiating settlement of a disputed claim. If for whatever reason your insurance company does not pay your claim in full, you are responsible for payment of the entire balance including any finance charges or collection fees that may be included.Signature * Clear Date Assignment of Benefits I hereby assign all medical benefits payable for serviced provided by Advanced Rheumatology of Houston including Medicare, private insurance and any other health plans to Advanced Rheumatology of Houston. I further authorize a release of any medical information necessary to process the claim and payment of benefits. A photocopy of this assignment is to be considered as valid as an original. This assignment remains in effect until I revoke in writing.Signature * Clear Date Request for Medical Records/All Additional Paperwork RequestsI understand and agree to pay the $25 fee for requesting a hard copy of my medical records and any other additional paperwork I would like the doctor to fill out. I understand that I will need to allow 72 hours for my medical records to be processed and 2 weeks for forms to be filled outSignature * Clear Date Medication Refill PolicyI understand that should I need any refills on my medications, it should be requested during my appointment with the doctor. I understand that should I make any requests outside of this time, I must allow 3-5 business days for my prescriptions to be filled. I take responsibility to call the office in the appropriate time frame in order for my medications to be refilled before I run out.Signature * Clear Date Please call the office for the Notice of the Privacy Practice 281-766-7886 Ext 1 Acknowledgement of Review of Notice of Privacy PracticesI have reviewed this office’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.Signature * Clear Date Name of Patient or Personal Representative INFORMED CONSENT AND PAIN MANAGEMENT AGREEMENT AS REQUIRED BY THE TEXAS MEDICAL BOARD REFERENCE: TEXAS ADMINISTRATIVE CODE, TITLE 22, PART 9, CHAPTER 170 3Rd Edition: Developed by the Texas Pain Society, April2008 (www.texaspain.org) NAME OF PATIENT: Date TO THE PATIENT: As a patient, you have the right to be informed about your condition and the recommended medical or diagnostic procedure or drug therapy to be used, so that you may make the informed decision whether or not to take the drug after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you, but rather it is an effort to make you better informed so that you may give or withhold your onsent/permission to use the drug(s) recommended to you by me, as your physician. For the purpose of this agreement the use of the word “physician” is defined to include not only my physician but also my physician’s authorized associates, technical assistants, nurses, staff, and other health care providers as might be necessary or advisable to treat my condition. CONSENT TO TREATMENT AND/OR DRUG THERAPY: I voluntarily request my physician (name at bottom of agreement) to treat my condition which has been explained to me as chronic pain. I hereby authorize and give my voluntary consent for my physician to administer or write prescription(s) for dangerous and/or controlled drugs (medications) as an element in the treatment of my chronic pain. It has been explained to me that these medication(s) include opioid/narcotic drug(s), which can be harmful if taken without medical supervision. I further understand that these medication(s) may lead to physical dependence and/or addiction and may, like other drugs used in the practice of medicine, produce adverse side effects or results. The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me as listed below. I understand that this listing is not complete, and that it only describes the most common side effects or reactions, and that death is also a possibility as a result from taking these medication(s). THE SPECIFIC MEDICATION(S) THAT MY PHYSICIAN PLANS TO PRESCRIBE WILL BE DESCRIBED AND DOCUMENTED SEPARATE FROM THIS AGREEMENT. THIS INCLUDES THE USE OF MEDICATIONS FOR PURPOSES DIFFERENT THAN WHAT HAVE BEEN APPROVED BY THE DRUG COMPANY AND THE GOVERNMENT (THIS IS SOMETIMES REFERRED TO AS “OFF-LABEL” PRESCRIBING). MY DOCTOR WILL EXPLAIN HIS TREATMENT PLAN(S) FOR ME AND DOCUMENT IT IN MY MEDICAL CHART. I HAVE BEEN INFORMED AND understand that I will undergo medical tests and examinations before and during my treatment. Those tests include random unannounced checks for drugs and psychological evaluations if and when it is deemed necessary, and I hereby give permission to perform the tests or my refusal may lead to termination of treatment. The presence of unauthorized substances may result in my being discharged from your care. For female patients only: To the best of my knowledge I am NOT pregnant. If I am not pregnant, I will use appropriate contraception/birth control during my course of treatment. I accept that it is MY responsibility to inform my physician immediately if I become pregnant. If I am pregnant or am uncertain, I WILL NOTIFY MY PHYSICIAN IMMEDIATELY. All of the above possible effects of medication(s) have been fully explained to me and I understand that, at present, there have not been enough studies conducted on the long-term use of many medication(s) i.e. opioids/narcotics to assure complete safety to my unborn child(ren). With full knowledge of this, I consent to its use and hold my physician harmless for injuries to the embryo/ fetus / baby. I UNDERSTAND THAT THE MOST COMMON SIDE EFFECTS THAT COULD OCCUR IN THE USE OF THE DRUGS USED IN MY TREATMENT INCLUDE BUT ARE NOT LIMITED TO THE FOLLOWING: constipation, nausea, vomiting, excessive drowsiness, itching, urinary retention (inability to urinate), orthostatic hypotension(low blood pressure), rrhythmias(irregular heartbeat), insomnia, depression, impairment of reasoning and judgment, respiratory depression (slow or no breathing), impotence, tolerance to medication(s), physical and emotional dependence or even addiction, and death. I understand that it may be dangerous for me to operate an automobile or other machinery while using these medications and I may be impaired during all activities, including work. The alternative methods of treatment, the possible risks involved, and the possibilities of complications have been explained to me, and I still desire to receive medication(s) for the treatment of my chronic pain. The goal of this treatment is to help me gain control of my chronic pain in order to live a more productive and active life. I realize that I may have a chronic illness and there is a limited chance for complete cure, but the goal of taking medication(s) on a regular basis is to reduce (but probably not eliminate) my pain so that I can enjoy an improved quality of life. I realize that the treatment for some will require prolonged or continuous use of medication(s), but an appropriate treatment goal may also mean the eventual withdrawal from the use of all medication(s). My treatment plan will be tailored specifically for me. I understand that I may withdraw from this treatment plan and discontinue the use of the medication(s) at any time and that I will notify my physician of any discontinued use. I further understand that I will be provided medical supervision if needed when discontinuing medication use. I understand that no warranty or guarantee has been made to me as to the results of any drug therapy or cure of any condition. The long-term use of medications to treat chronic pain is controversial because of the uncertainty regarding the extent to which they provide long-term benefit. I have been given the opportunity to ask questions about my condition and treatment, risks of non-treatment and the drug therapy, medical treatment or diagnostic procedure(s) to be used to treat my condition, and the risks and hazards of such drug therapy, treatment and procedure(s), and I believe that I have sufficient information to give this informed consent. PAIN MANAGEMENT AGREEMENT: I UNDERSTAND AND AGREE TO THE FOLLOWING: That this pain management agreement relates to my use of any and all medication(s) (i.e., opioids, also called ‘narcotics, painkillers’, and other prescription medications, etc.) for chronic pain prescribed by my physician. I understand that there are federal and state laws, regulations and policies regarding the use and prescribing of controlled substance(s). Therefore, medication(s) will only be provided so long as I follow the rules specified in this Agreement. My physician may at any time choose to discontinue the medication(s). Failure to comply with any of the following guidelines and/or conditions may cause discontinuation of medication(s) and/or my discharge from care and treatment. Discharge may be immediate for any criminal behavior: • My progress will be periodically reviewed and, if the medication(s) are not improving my quality of life, the medication(s) may be discontinued. • I will disclose to my physician all medication(s) that I take at any time, prescribed by any physician. • I will use the medication(s) exactly as directed by my physician. • I agree not to share, sell or otherwise permit others, including my family and friends, to have access to these medications. • I will not allow or assist in the misuse/diversion of my medication; nor will I give or sell them to anyone else. • All medication(s) must be obtained at one pharmacy, where possible. Should the need arise to change pharmacies, my physician must be informed. I will use only one pharmacy and I will provide my pharmacist a copy of this agreement. I authorize my physician to release my medical records to my pharmacist as needed. • I understand that my medication(s) will be refilled on a regular basis. I understand that my prescription(s) and my medication(s) are exactly like money. If either are lost or stolen, they may NOT BE REPLACED. • Refill(s) will not be ordered before the scheduled refill date. However, early refill(s) are allowed when I am traveling and I make arrangements in advance of the planned departure date. Otherwise, I will not expect to receive additional medication(s) prior to the time of my next scheduled refill, even if my prescription(s) run out. • I will receive medication(s) only from ONE physician unless it is for an emergency or the medication(s) that is being prescribed by another physician is approved by my physician. Information that I have been receiving medication(s) prescribed by other doctors that has not been approved by my physician may lead to a discontinuation of medication(s) and treatment. • If it appears to my physician that there are no demonstrable benefits to my daily function or quality of life from the medication(s), then my physician may try alternative medication(s) or may taper me off all medication(s). I will not hold my physician liable for problems caused by the discontinuance of medication(s). • I agree to submit to urine and/or blood screens to detect the use of non-prescribed and prescribed medication(s) at any time and without prior warning. If I test positive for illegal substance(s), such as marijuana, speed, cocaine, etc., treatment for chronic pain may be terminated. Also, a consult with, or referral to, an expert may be necessary: such as submitting to a psychiatric or psychological evaluation by a qualified physician such as an addictionology’s or a physician who specializes in detoxification and rehabilitation and/or cognitive behavioral therapy/psychotherapy. • I recognize that my chronic pain represents a complex problem which may benefit from physical therapy, psychotherapy, alternative medical care, etc. I also recognize that my active participation in the management of my pain is extremely important. I agree to actively participate in all aspects of the pain management program recommended by my physician to achieve increased function and improved quality of life. • I agree that I shall inform any doctor who may treat me for any other medical problem(s) that I am enrolled in a pain management program, since the use of other medication(s) may cause harm. • I hereby give my physician permission to discuss all diagnostic and treatment details with my other physician(s) and pharmacist(s) regarding my use of medications prescribed by my other physician(s). • I must take the medication(s) as instructed by my physician. Any unauthorized increase in the dose of medication(s) may be viewed as a cause for discontinuation of the treatment. • I must keep all follow-up appointments as recommended by my physician or my treatment may be discontinued. I certify and agree to the following: 1) I am not currently using illegal drugs or abusing prescription medication(s) and I am not undergoing treatment for substance dependence (addiction) or abuse. I am reading and making this agreement while in full possession of my faculties and not under the influence of any substance that might impair my judgment. 2) I have never been involved in the sale, illegal possession, misuse/diversion or transport of controlled substance(s) (narcotics, sleeping pills, nerve pills, or painkillers) or illegal substances (marijuana, cocaine, heroin, etc.) 3) No guarantee or assurance has been made as to the results that may be obtained from chronic pain treatment. With full knowledge of the potential benefits and possible risks involved, I consent to chronic pain treatment, since I realize that it provides me an opportunity to lead a more productive and active life. 4) I have reviewed the side effects of the medication(s) that may be used in the treatment of my chronic pain. I fully understand the explanations regarding the benefits and the risks of these medication(s) and I agree to the use of these medication(s) in the treatment of my chronic pain. Signature * Clear Date Name and contact information for pharmacy ADVANCED RHEUMATOLOGY OF HOUSTON Patient Consent for Use of Email Communications Letter To better serve our patients, this office has established an email address for some forms of communication. For routine matters that do not require immediate response, please feel free to contact us at email@example.com. Please remember however, that this form of communication is not appropriate for use in an emergency. The turnaround time for routine patient communications is 24-48 hours. The service provider may delay message delivery. Should you require urgent or immediate attention, this medium is not appropriate. When sending email, please put the subject of your message in the subject line so we can process it more efficiently. Also, be sure to put your name, date of birth, and return telephone number in the body of the message. We also ask that you acknowledge receipt of emails coming from this office by using the auto reply feature. Communications relating to diagnosis and treatment will be filed in your medical record. This office is dedicated to keeping your medical record information confidential. Despite our best efforts, due to the nature of email, third parties may have access to messages. When communicating from work, you should be aware that some companies consider email corporate property and your messages may be monitored. Even when emailing from home, you may feel that access to your email is not well controlled, so you should take that into consideration. In addition, you should be aware that, although addressed to me, my staff and/or colleagues would have access to this information. I understand that this office will not be responsible for information loss or delay, or breaches in confidentiality that are due to technical factors beyond this office’s control. I understand and agree to the above email policy. By signing below, you are agreeing that we may send medical related correspondence to you via email, and that we may respond to your emails to us via email.Patient signature * Clear Witness (optional) Clear Date Cancellation and No-Show Policy We are dedicated to helping our patients and appreciate those who value this dedication of time, energy, and service. In order to provide patient access to the clinic we require that all patients let us know at least 24 hours in advance of their scheduled appointment time that they will not be able to make it. Our schedule is often full and last-minute cancellations and no shows adversely affect other patients ability to receive treatment. • All No-show appointments will result in a fee of $50.00. A patient may be subject to be discharge from the clinic if they have 2 or more cancellations, No shows, and/or rescheduled appointments. • If you arrive later than 15 minutes to your appointment without Calling, Texting or Emailing the office, be prepared to be rescheduled and to charged a No-show fee of $50.00. We appreciate your cooperation and understanding. Signature * Clear Date Submit If you are human, leave this field blank.