The following forms are essential elements in your diagnosis and treatment by our pain specialists. The links below will allow you to download, print and fill out the requested forms at your convenience prior to your scheduled appointment.
General Consent Form
I consent to routine medical nursing care including routine procedures, examinations, tests, immunizations, regional and local anesthesia and other treatment by Dr. Quiroga and his assistants.
Consent
Additional Consent
Release Of Information
Insurance
No Guarantees
Personal Property
Notice of Privacy Practice
New Patient Pain/Spine Intake Form
What is the main problem that brings you here today.
Referring Physician
Primary Care Physician
Pain History
Medical History
Work Status
Medications
Allergies
Patient Intake Form
Referral info
Primary insurance provider info
Emergency contact info
Pain Level Questionnaire
Description of current pain issues
Associated problems caused by pain
Updates to medical/surgical history
Pain management goals
HIPAA Acknowledgement
Acknowledgement of receipt of Michigan Advanced
Pain & Spine notice of privacy practices
Medical Records Release Form
Authorization of disclosure of patients' medical history
by Michigan Advanced Pain & Spine
Low Back Disability Questionnaire
Designed to give the doctor information as to how
your back pain has affected your ability to manage in
everyday life: personal care, walking, sleeping, social
life, travel, etc.
Headache Disability Index
To identify frequency of and difficulties you may be
experiencing due to headaches
Opioid Risk Tool
This form importantly appraises personal and family
history of alcohol or other substance abuse,
psychological disorders or sexual abuse.
Balance Self-Test
This form is an assessment of any issues with balance,
dizziness, falls, hearing loss and of your need of
assistance to walk or stand.
Narcotic Medication Agreement
This series of statements is designed to insure that
you understand the various risks and responsibilities
that go along with these treatments.
COMM
This self-assessment helps our clinicians monitor
patients' medication-related behaviors over the course
of treatment.
SOAPP-R
This form assists clinicians consider which patients
may exhibit aberrant medications behaviors in the
future.
Legal Authorization
This form authorizes Michigan Advanced Pain & Spine
to furnish your attorney with a full report of your exam,
diagnosis, treatment, prognosis, etc. in regard to an
accident/injury in which you were involved.
