Martin F. Quiroga, DO
Mohan YS, M.D.
Steven Petrovas, M.D.
27101 Schoenherr Road
Suite 200 Warren, MI (586) 806-6466
MAPS has taken the Pledge
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.
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
What is the main problem that brings you here today.
Referring Physician
Primary Care Physician
Pain History
Medical History
Work Status
Medications
Allergies
Description of current pain issues
Effects on lifestyle/activities
Associated problems caused by pain
Updates to medical/surgical history
Pain management goals
Acknowledgement of receipt of Michigan Advanced Pain & Spine notice of privacy practices
Authorization of disclosure of patients' medical history by Michigan Advanced Pain & Spine
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.
To identify frequency of and difficulties you may be experiencing due to headaches
This form importantly appraises personal and family history of alcohol or other substance abuse, psychological disorders or sexual abuse.
This form is an assessment of any issues with balance, dizziness, falls, hearing loss and of your need of assistance to walk or stand.
This series of statements is designed to insure that you understand the various risks and responsibilities that go along with these treatments.
This self-assessment helps our clinicians monitor patients' medication-related behaviors over the course of treatment.
This form assists clinicians consider which patients may exhibit aberrant medications behaviors in the future.
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.