Copyright © 2018 Michigan Advanced Pain & Spine

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.

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Additional Consent

Release Of Information

Insurance

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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

Referral info

Primary insurance provider info

Emergency contact info

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.

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