Patient Registration

First Name *

Last Name *

Date of birth: *

Social Security Number 🛈

Sex *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number: Home

Phone Number: Cell

Email Address

May we contact you via email? *

Yes

No

May we send you text messages? *

Yes

No

Who is your family physician? *

Marital status *

Single

Married

Divorced

Widowed

What is your insurance? *

Who is the Insurance Subscriber? *

If the Insurance Subscriber is a spouse or parent, please provide their name and DOB.

Insurance ID # *

Insurance Group # *

IS YOUR VISIT DUE TO A WORK-RELATED INJURY, AN AUTOMOBILE ACCIDENT, OR A PERSONAL INJURY CLAIM? *

Yes

No

Patient Acknowledgment of Receipt of Notice of Privacy Practices

I, the undersigned, hereby acknowledge that I have reviewed and received a copy of this office's Notice of Privacy Practices explaining:

1. How this office will use and disclose my protected health information.

2. My privacy rights with regard to my protected health information.

3. This office's obligations concerning the use and disclosure of my protected health information.

I understand that the Notice of Privacy Practices may be revised from time to time and that I an entitled to receive a copy of any new revised practices upon request.

I also understand that if I have questions or complaints, I may contact:

Ricardo M. Buenaventura, MD

7244 Far Hills Ave.

Centerville, OH 45459

937-395-1300

You may also contact the Secretary of the U.S. Department of Health and Human Services with any concerns regarding our privacy and security policies and procedures. Please contact our office for information on how to contact the U.S Department of Health and Human Services.

To Review a copy of our Privacy Policy, click here: https://www.painreliefofdayton.com/your-privacy

Patient or Personal Representative

Name: *

Today's Date: +

Relationship to Patient: *

Signature: *

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A Letter to Our Patients Regarding Our Role in Your Care

Dear Patient,

We are happy to see you in our practice. We utilize a wide array of therapies and non-addicting medications to minimize and control your pain. Our goal is to do this without the use of narcotics or controlled pain medications. In most cases, we prefer not to prescribe or escalate any controlled pain medicines you are currently taking.

Several new procedures and non-controlled pain medicines have been developed in the last few years. Our approach is to implement these therapies and medications into your treatment regimen. We will evaluate your case and offer the most reasonable, safe, and beneficial treatment for you. We may also use/recommend physical therapy.

We will make suggestions to your referring physician about what medicines, including controlled medicines, we think are right for you and your condition. We may start you on some non-controlled pain medicines and then turn these over to your primary care doctor for the continuance of these. Other times we may suggest all the medicines to him/her so that they may decide which are safe and best in your case.

Hopefully, through the use of these pain-relieving procedures and non-narcotic pain medications, we can minimize or delay the need for controlled substances. This will delay the development of tolerance or dependence on these medicines later. Please keep in contact with your primary care physician and make sure you have enough medicine to get back into their clinic.

From all of us at Pain Relief of Dayton, we look forward to seeing you and making your evaluation a pleasant one.

Patient Signature: *

Today's Date: * +

Initial Consent for Treatment

I desire to be treated at Pain Relief of Dayton by Dr. Ricardo Buenaventura. I understand that I may discontinue treatment at any time. I authorize for the examination, diagnosis, and general treatment which may include but not limited to clinical evaluation, medical history, physical examination, psychological examination. The purpose of such evaluations is to assist in identifying the cause of my problem and applying the most appropriate medical treatments possible. I understand and consent to the administration of an evaluation. After my evaluation, my doctor may offer treatment options which may include but are not limited to non-narcotic medications, physical therapy, injection therapy, chiropractic treatments, diagnostic imaging, or psychological therapy as considered necessary and advised by my physician.

I understand that treatments provided by Pain Relief of Dayton are voluntary and in no way guaranteed to relieve my pain fully or completely.

Patient Signature: *

Today's Date: * +

Office Policies

MISSED APPOINTMENT POLICY

Not Keeping scheduled appointments hinders our ability to provide quality care. We require a 24-hour notice for all cancellations. This allows us to offer your time slot to another patient. A failure to provide cancellation notice will result in a $25.00 fee to your account. This is not payable by your insurance and will be your responsibility.

CO-PAYMENTS AND DEDUCTIBLES

All co-payments, co-insurance, and unmet deductible amounts will be due at the time of service. Our office will make every effort to notify you of any deductible amounts due but ultimately you are responsible for knowing this information.

FINANCIAL AGREEMENT

I understand it is my responsibility to know my insurance benefits, including whether the physician is contracted with my insurance company, my covered benefits, and any exclusions in my insurance policy. I understand that the bill is my responsibility. I assign payments to be made directly to Pain Relief of Dayton for all insurance benefits and agree to pay any balance due. I understand I will be responsible for any additional fees incurred from the following: Returned Checks, Missed Appointments, Copies of Medical Records.

Patient Name: *

0/255 characters

Today's Date: * +

Confidential Communication

As required by the Health Information Portability and Accountability Act of 1996 (HIPAA), you have the right to request that communications concerning your personal health information be made through confidential channels.

I request the use of the following confidential channels for the communication of information related to my personal health, treatment, testing results, or appointment reminders:

I prefer to be contacted at this primary phone number: *

May we leave a detailed message at this primary number? *

Yes

No

If there are any people with whom we may discuss your health information, please list them: *

Patient Signature: *

Today's Date: * +

Opioid Risk Tool

Name: *

Date of Birth: *

Today's Date: * +

Are you: *

Male

Female

Do you have a Family History of Substance Abuse? *

Alcohol (F1/M3)

Illegal Drugs (F2/M3)

Prescription Drugs (F4/M4)

None

Do you have a Personal History of Substance Abuse? *

Alcohol (F3/M3)

Illegal Drugs (F4/M4)

Prescription Drugs (F5/M5)

None

Are you between the ages of 16-45? *

Yes (F1/M1)

No

Do you have a history of Preadolescent Sexual Abuse? *

Yes (F3/M0)

No

Do you have any of the following psychological disorders: Attention Deficit Disorder, OCD, Bipolar, Schizophrenia *

Yes (F2/M2)

No

Have you been diagnosed with depression? *

Yes (F1/M1)

No

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FOR OFFICE USE ONLY

TOTAL __________________

Total Score Risk Category
Low Risk 0-3
Moderate Risk 4-7
High Risk 8+

Personal and Family Medical History

Mark the medical conditions that apply to you or any immediate family

	Personal	Sibling	Mother	Father
Seasonal Allergies	Personal	Sibling	Mother	Father
Anemia	Personal	Sibling	Mother	Father
Anxiety	Personal	Sibling	Mother	Father
Arthritis	Personal	Sibling	Mother	Father
Asthma	Personal	Sibling	Mother	Father
Cancer	Personal	Sibling	Mother	Father
Cataracts	Personal	Sibling	Mother	Father
Thyroid Disease	Personal	Sibling	Mother	Father
CHF	Personal	Sibling	Mother	Father
Clotting Disorder	Personal	Sibling	Mother	Father
COPD	Personal	Sibling	Mother	Father
Depression	Personal	Sibling	Mother	Father
Diabetes	Personal	Sibling	Mother	Father
GERD	Personal	Sibling	Mother	Father
Heart Murmur	Personal	Sibling	Mother	Father
HIV/AIDS	Personal	Sibling	Mother	Father
Hyperthyroidism	Personal	Sibling	Mother	Father
Hypothyroidism	Personal	Sibling	Mother	Father
Kidney Disease	Personal	Sibling	Mother	Father
Heart Problems	Personal	Sibling	Mother	Father
MI	Personal	Sibling	Mother	Father
Nerve Trouble	Personal	Sibling	Mother	Father
Osteoporosis	Personal	Sibling	Mother	Father
Seizures	Personal	Sibling	Mother	Father
Stroke	Personal	Sibling	Mother	Father
Substance Abuse	Personal	Sibling	Mother	Father
High Blood Pressure	Personal	Sibling	Mother	Father
Tuberculosis	Personal	Sibling	Mother	Father
Ulcers	Personal	Sibling	Mother	Father
High Cholesterol	Personal	Sibling	Mother	Father
Gout	Personal	Sibling	Mother	Father
Glaucoma	Personal	Sibling	Mother	Father
Hepatitis C	Personal	Sibling	Mother	Father

Comments or other medically-relevant issue

Personal Surgical History

Have you had any of the following surgeries? *

Additional surgeries or comments:

Social History

Product use

	None	Occasionally	Weekly	Daily
Alcohol	None	Occasionally	Weekly	Daily
Tobacco	None	Occasionally	Weekly	Daily
Recreational drugs	None	Occasionally	Weekly	Daily
Caffeine	None	Occasionally	Weekly	Daily
Exercise Daily	None	Occasionally	Weekly	Daily

Review of Systems

Check any that may apply to you: *

Tell Us About Yout Current Pain Condition

Where is your pain located? Be descriptive. *

Chronicity: *

New

Recurrent

Chronic

Onset: *

Frequency: *

Progression Since Onset: *

Pain Quality:

Pain Radiates to: *

Pain Score. from 0-10 with 0 being no pain, and 10 being the worst pain, how would you rate your pain on average: *

Pain Severity: *

No Pain

Mild

Moderate

Severe

Pain is aggravated by:

Pain is:

Worse during the day

Worse during the evening/night

Same all the time

Stiffness is Present:

In the morning

At night

All the time

I have no stiffness

Do you have any of the following associated with this condition: *

Do you have any of the following risk factors: *

Have you tried any of the following treatments for your pain: *

How long have you tried those treatments: *

How much relief did you receive from those treatments:

Does the pain affect your sleep:

Trouble falling asleep

Medication is needed to fall asleep

I am awakened by the pain

How long are you able to sit and/or stand before you have to stop/rest? *

My pain impacts/affects my life in the following ways, select all that apply:

Do any of the following apply to you: *

What is your occupation?

Please list any other physicians that you have seen or who have treated your for this condition:

Do any of the following things improve your pain:

Current Medication

List any current medications you are taking. If you have your own list, you may bring that to your appointment instead.

	Name	Dose	How long have you been taking?
1	Name	Dose	How long have you been taking?
2	Name	Dose	How long have you been taking?
3	Name	Dose	How long have you been taking?
4	Name	Dose	How long have you been taking?
5	Name	Dose	How long have you been taking?
6	Name	Dose	How long have you been taking?
7	Name	Dose	How long have you been taking?

Do you have any drug allergies? *

Yes

No

If yes, please explain:

Do you take a blood thinner medication: *

Yes

No

Comments or additional information you would like the doctor to know:

Completion

By signing below I certify that the information I have provided above is accurate to the best of my knowledge.

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DATE: * +

I have had no surgeries	Appendectomy	Brain Surgery
Gall Bladder	Eye Surgery	Spine Surgery
Tonsillectomy	Breast Surgery	Colon
Hernia Repair	Valve Replacement	Joint Replacement
CABG	C-Section	Hysterectomy

None Of These Apply To Me	Change in activity level	Change in Appetite	Chills	Sweating
Fatigue	Fever	Weight Gain	Weight Loss	Facial Swelling
Neck Pain	Neck Stiffness	Ear Discharge	Hearing Loss	Ear Pain
Tinnitus	Nosebleeds	Congestion	Runny Nose	Postnasal Drip
Sneezing	Dental Problems	Drooling	Mouth SOres	Trouble Swallowing
Voice Change	Eye Discharge	Eye Itching	Eye Pain	Eye Redness
Photophobia	Visual Disturbance	Apnea	Chest Tightness	Shortness of Breath
Choking	Cough	Stridor	Wheezing	Chest Pain
Leg Swelling	Palpitations	Abdominal Distension	Abdominal Pain	Anal Bleeding
Rectal Pain	Blood in Stool	Constipation	Diarrhea	Nausea
Vomiting	Difficulty Urination	Flank Pain	Urinary Frequency	Genital Sore
Menstrual Problems	Pelvic Pain	Urgency	Decreased Urine	Vaginal Bleeding
Vaginal Discharge	Vaginal Pain	Muscle Pain	Back Pain	Trouble Walking
Joint Pain	Joint Swelling	Rash	Itching	Color Changes to the Skin
Dizziness	Facial Asymmetry	Headaches	History of Migraines	Light-Headedness
Numbness	Seizures	Weakness	Tingling	Tremors
Speech Difficulty	Clotting Disorders	Anemia	Bruises Easily	Agitation
Behavior Problem	Confusion	Hyperactive	Anxiety	Depression
Bi-Polar	OCD	Suicidal Thoughts

Unchanged	Gradually Improving	Rapidly Improving	Comes and Goes
Gradually Worsening	Rapidly Worsening	Resolved

Pain does not radiate	Right Leg/Foot	Left Leg/Foot	Right Arm/Hand
Left Arm/Hand	Right Hip/Thigh/Groin	Left Hip/Thigh/Groin

None	Abdominal Pain	Bladder Incontinence	Bowel Incontinence
Chest Pain	Fever	Headaches	Leg Pain
Numbness	Pelvic Pain	Tingling	Weakness
Weight Loss

I have not tried any treatments	Oral Medications	Topical Medications
Bed Rest	Chiropractic Treatments	Heat
Ice	Home Stretching/Exercises	Walking
Injections	Surgery	Physical Therapy

0-10 minutes	10-20 minutes	20-40 minutes
over 45 minutes	I am able to stand and walk for any length

Work Duties	Activities of Daily Living
Recreational Activities	Sexual Relations
Home Duties	Concentration
Walking/Climbing Stairs	Dressing/Bathing
Performing Errands

I am involved in a legal proceeding for my pain condition	I receive Disability Benefits
I am Employed Full-Time	I am Employed Part-Time
Retired	Unemployed
Looking for work	I have received psychological counseling for my PAIN condition
N/A

Liquor	Heat	Massage/Pressure	No Movement
Movement	Rest/Sleep	Cold	Distraction
Working	Mild Exercise

None	Cancer	Osteoporosis	Steroid Use
Lack of Exercise	Menopause	Obesity	Poor Posture
Pregnancy	Recent Trauma	Sedentary Lifestyle

1-4 weeks	4-6 weeks	6-12 weeks
More than 12 weeks	N/A