Forms


 

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. 

Form

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

Download


Form

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

Download


Form

Patient Intake Form

Referral info
Primary insurance provider info
Emergency contact info

Download


Form

Pain Level Questionnaire

Description of current pain issues
Associated problems caused by pain
Updates to medical/surgical history
Pain management goals

Download


Form

HIPAA Acknowledgement

Acknowledgement of receipt of Michigan Advanced
Pain & Spine notice of privacy practices

Download


Form

Medical Records Release Form

Authorization of disclosure of patients' medical history
by Michigan Advanced Pain & Spine

Download


Form

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.

Download


Form

Headache Disability Index

To identify frequency of and difficulties you may be
experiencing due to headaches

Download


Form

Opioid Risk Tool

This form importantly appraises personal and family
history of alcohol or other substance abuse,
psychological disorders or sexual abuse.

Download


Form

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.

Download


Form

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.

Download


Form

COMM

This self-assessment helps our clinicians monitor
patients' medication-related behaviors over the course
of treatment.

Download


Form

SOAPP-R

This form assists clinicians consider which patients
may exhibit aberrant medications behaviors in the
future.

Download


Form

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.

Download

Location
Michigan Advanced Pain & Spine
27101 Schoenherr Road, Suite 200
Warren, MI 48088
Phone: 586-200-4698
Fax: 586-806-6395
Office Hours

Get in touch

586-200-4698