@ Weill Corneil Phone: (888) 922-2257 (888-WC-BACKS) Center for Comprehensive Please return this form to our office via fax. (646)-962-0640 Spine Care ***For Eric Elowitz, MD; Kai-Ming Fu, MD; and Attn: Jude Anthony AGarcia Ali A. Baaj, MD; please return forms to (646) 962-0119 Please note which department or physician you are requesting to see: _|\i2 . 1} ARTL. Neurosurgery Neurology Pain Management Physiatry/Rehab Medicine NEW PATIENT QUESTIONNAIRE pare: Jal. | 4,201 ers Date of Birth: Ol / 30/1953 Gender:(Wror F ress: 9 CAS ls O ‘We Insurance Carrier/ ID or Policy # Reason for Visit: Have you had a history of accident or injury? If yes, please explain and answer the next three questions: ° Was the accident at work? Yes or No * Are you using Workman’s Compensation? Yes or No © — Are you currently involved in litigation? Yes or No On the diagram below, please mark where you are feeli ir symptoms with the appropriate letters. ga al Ona scale of 0 to 10, please circle your level of pain or discomfort O being none and 10 being unbearable for the following areas: 1. Neck Pain: 0123 45 678 9 10 2. LeftShoulderPain: © 1 2 3 45 6 7 8 9 19 3. Right Shoulder Pain: 0 1 2 3 4 5 6 7 8 9 19 4. Left Arm Pain: a ne eo eT) 5. Right Arm Pain: 012345 678 9 19 6. Back Pain: Fie Saw 7 8 oO 7. Left Hip/ButtockPain: 0 1 2 3 4 5 6 7 8 9 10 8. Right Hip/Buttock Pain:}0 1 2 3 4 5 6 7 8 9 49 9. Left Leg Pain: S tee C556 F ee io 10. Right Leg Pain: 012345 678 9 10 A= ACHE 11. Left Foot Pain: eo. 2°68 4:3 2°59 So 10 B= BURNING 12. Right Foot Pain: 912345 6789 10 N= NUMBNESS * ma If you are not experiencing pain as a symptom, O= OTHER please skip Questions 1-7, Please note if other: 3. What makes the better (check all that applies)? 1. When did the pain begin? Heat e 4 Cold Bend Forward Bend Back Change Position ( Sitting Duration of Pain: a Standing Walking Twisting Movement Change in weather Lying Supine Overall the pain is: Rest Valsalva Coughing/Sneezing Improved Worse Stable Nothing Sex N/A 4. What makes the pain worse (check all that applies)? 2. Quality of Pain (check all that applies)? Aon can eee — Sore Aching” Burning Bend Back Change Position ) Sitting Sharp Dull Tender Standing Walking Twisting Stabbing Tingling Cramping Movement Change in weather Lying Supine Shooting Pulling Radiating Rest Valsalva Coughing/Sneezing Unsure Throbbing Nothing Sex N/A EFTA00313804

--=PAGE_BREAK=--

5. Pain interferes with: 7. If pain limits activity, please full in all that apply: Sleep | Appetite ) Sex . ; SelEC. Hobbies 0 Job Perf {can't tolerate walking more than Mocks. ) Driving Social Life Exercise I can’t tolerate sitting more than ___—_minutes. Lifting Traveling Shopping I can’t tolerate standing more than minutes. Resatiald Chane faking I can’t tolerate lying more than minutes, 6. When is the pain worst? (Circle one) 8. Do you experience weakness? Yes or No Morning Afternoon Evening Night Ifyes, please describe (include location) Have you had any of the following imaging studies? If yes, please include the date. IF SO, PLEASE FORWARD A COPY OF THE REPORT TO THE OFFICE PRIOR TO YOUR APPOINTMENT! uei_ Der. 14, 501 NOv.2 301IT X-ray Bone Scan. CT scan EMG Below, indicate past treatments for your neck/back condition and include the date of treatment: DR. CHEN Nerve Block Steroid injections_ JUNE | 20} Junie 15,2013 Physical Therapy. Psychotherapy Acupuncture. Surgery. Chiropractic. Failed Medications Othe If surgery is recommended, what would be your timeframe available for scheduling? REVIEW OF SYSTEMS: GENERAL ENDROCRINE NEUROLOGICAL Fatigue © NO o YES Thyroid condition [) NO [) YES Dizziness/Vertigo NO a YES Weight loss o NO c YES Diabetes [] NO ["] Yes Headaches 0 NO 0 YES Weakness 5 NO 0 YES Other Strokes o NO 0 YES Swollen Lymph nodes NO co YES Seizures 0 NO 0 YES KIDNEY Tremor co NO a YES HEAD Difficulty in passing urine a NO a YES Numbness 6 NO c YES Visual problems NO 0 YES Getting up at night to urinate o NO c YES Ear pain, decreased hearing o NO o YES PSYCHOLOGICAL Difficulty swallowing 0 NO o YES GASTROINTESTINAL Anxiety 0 NO o YES ae Poor appetite [7] NO ["] YES Depression 5 NO 0 YES Indigestion or vomiting (] NO [7] Yes 2 ee CHEST, HEART, AND LUNGS Change in bowel habits [~] NO ["] Yes Shortness of breath o NO 0 YES Pass blood from rectum [] NO [-] YES History of Cancer? Yes No Chest pain or pressure attacks 0 NO o YES If yes, type: Frequent cough 5 NO o YES MUSCULOSKELETAL Chemo: Yes No papa Decreased Range of Motion NO a YES Radiation: No Valve disorder 0 NO a Joint Swelling o NO o YES Sleep Apnea 5 NO o YES Joint Stiffness o NO o YES Please notify the MD/NP/PA/RN if you are OVT a NOYES Pregnant: Yes No 5 GNOO YES Muscle Aches/Pains c NO co YES Other, EFTA00313805

--=PAGE_BREAK=--

Any allergies to: Shellfish lodine Latex Contrast/IV dye 1. Are you a: Current Smoker / Never Smoker / Former Smoker Quit Date: Type: Packs/day: ‘Vers: 2. Do you use chewing and/or smokeless tobacco? Yes or No Have you quit? Yes or No When? 3. Doyou drink alcohol? Yes or No Type(s): Amount: How often: 4. Do you use illicit (street) drugs? Yes or No Type(s): Last used: 5. Marital Status: Gingl@) Married —_Cohabitating Separated Divorced Widowed 6. Whodoyoulive with? Alone Spouse Children Parents Other: 7. What is your occupation? 8. Are youdisabled? Yes or No If yes, note disability: Medical/Personal History: Are you right- or left-handed? Right Left Ambidextrous Past Medical History: etn ele ee ooo ee nena eneeeeitneNNsbhosiuaaieocne obanaoa Past Surgical History and Dates: CO — i Family Medical History: eer Please share any other information you would like us to know: Sa cg Preferred Pharmacy: Name: Phone Number: eee i Address: If this form was completed by someone other than the patient, please list the name, relation to the patient and the reason that the patient was unable to complete the form. Form Completed by. Date eee EFTA00313806

--=PAGE_BREAK=--

anower Dy cho ae been designed to give us infomation as to how your back or leg pain is affecting your abt to manage in everyday te. Please any one econ aay tet an. each section for the statement which Dest applies to you. We realize you may covsider tat mio Gr monn fone, problem. any one section apply but please just shade out the spot that indicates the s Section 1: Pain Intensity © | have no pain at the moment © The pain is very mild at the moment © The pain is moderate at the moment © The pain is fairly severe at the moment © The pain is very severe at the moment © The pain is the worst imaginable at the moment Section 2: Personal Care (eg. washing, dressing) © I can look after myself normally without causing extra pain © | can look after myself normally but it causes extra pain © It is painful to look after myself and | am slow and careful © | need some help but can manage most of my personal care © | need help every day in most aspects of self-care © 1 do not get dressed, wash with difficulty and stay in bed Section 3: Lifting © | can lift heavy weights without extra pain © I can lift heavy weights but it gives me extra pain © Pain prevents me lifting heavy weights off the floor but | can manage if they are conveniently placed (eg. on a table) © Pain prevents me lifting heavy weights but | can manage light to medium weights if they are conveniently positioned © I can only lift very light weights © | cannot lift or carry anything Section 4: Walking* © Pain does not prevent me walking any distance © Pain prevents me from walking more than 1 mile © Pain prevents me from walking more than % mile © Pain prevents me from walking more than 100 yards © | can only walk using a cane or crutches © | am in bed most of the time Section 5: Sitting © I can sit in any chair as long as | like © I can only sit in my favorite chair as long as | like © Pain prevents me sitting more than one hour © Pain prevents me from sitting more than 30 minutes © Pain prevents me from sitting more than 10 minutes © Pain prevents me from sitting at alll tatement which most clearly describes your Section 6: Standing © | can stand as long as | want without extra pain © I can stand as long as | want but it gives me extra pain © Pain prevents me from standing for more than 1 hour © Pain Prevents me from standing for more than 30 minutes © Pain prevents me from standing for more than 10 minutes © Pain prevents me from standing at all Section 7: Sleeping © My Sleep is never disturbed by pain © My sleep is occasionally disturbed by pain © Because of pain | have less than 6 hours © Because of pain | have less than 4 hours sleep © Because of pain | have less than 2 hours sleep © Pain prevents me from sleeping at all Section 8: Sex Life (if applicable) © My sex life is normal and causes no extra pain © My sex life is normal but causes some extra pain © My sex life is nearly normal but is very painful © My sex life is restricted by pain © My sex life is nearly absent because of pain © Pain prevents any sex life at all Section 9: Social Life © My social life is normal and gives me no extra pain © My social life is normal but increases the degree of pain © Pain has no significant effect on my social life apart from limiting my more energetic interests e.g. sport © Pain has restricted my social life and | do not go out as often © Pain has restricted my social life to my home © | have no social life because of pain Section 10: Travelling © | can travel anywhere without pain ° | can travel anywhere but it gives me extra pain © Pain is bad but | manage journeys over two hours © Pain restricts me to journeys of less than one hour © Pain restricts me to short necessary journeys under 30 minutes © Pain prevents me from travelling except to receive treatment EFTA00313807

--=PAGE_BREAK=--

©@ Weill Cornell Medicine Center for Comprehensive Spine Care Neck Disability Index This questionnaire has been designed to give us information as to how your neck pain has affected your ability to manage in everyday life. One section relate to you, ur please pate" Only the one box that apples to you. We realize you may consider that two or more statoniete nt any one section relate to you, but please just mark the box that most closely describes your problem. Section 1: Pain Intensity © | have no pain at the moment © The pain is very mild at the moment © The pain is moderate at the moment © The pain is fairly severe at the moment © The pain is very severe at the moment © The pain is the worst imaginable at the moment Section 2: Personal Care (Washing, Dressing, etc.) © | can look after myself normally without causing extra pain © | can look after myself normally but it causes extra pain 9 It is painful to look after myself and | am slow and careful © | need some help but can manage most of my personal care © I need help every day in most aspects of self care © I do not get dressed, | wash with difficulty and stay in bed Section 3: Lifting © | can lift heavy weights without extra pain © | can lift heavy weights but it gives extra pain © Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table © Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned © I can only lift very light weights © | cannot lift or carry anything Section 4: Reading © | can read as much as | want to with no pain in my neck © | can read as much as | want to with slight pain in my neck © | can read as much as | want with moderate pain in my neck © I can't read as much as | want because of moderate pain in my neck © I can hardly read at all because of severe pain in my neck © I cannot read at all Section 5: Headaches © | have no headaches at all © | have slight headaches, which come infrequently © | have moderate headaches, which come infrequently © | have moderate headaches, which come frequently © | have severe headaches, which come frequently © | have headaches almost all the time Section 6: Concentration © | can concentrate fully when I want to with no difficulty © | can concentrate fully when | want to with slight difficulty i of difficulty in concentrating when | want © | have a lot of difficulty in concentrating when | want ° | have a great deal of difficulty in concentrating when | want © | cannot concentrate at all Section 7: Work © | can do as much work as | want to © I can only do my usual work, but no more © | can do most of my usual work, but no more © I cannot do my usual work © I can hardly do any work at alll © | can't do any work at all Section 8: Driving © I can drive my car without any neck pain © I can drive my car as long as | want with slight pain in my neck © | can drive my car as long as | want with moderate pain in my neck © | can't drive my car as long as | want because of moderate pain in my neck © | can hardly drive at all because of severe pain in my neck © | can't drive my car at all Section 9: Sleeping © | have no trouble sleeping © My sleep is slightly disturbed (less than 1 hr sleepless) © My sleep is mildly disturbed (1-2 hrs sleepless) © My sleep is moderately disturbed (2-3 hrs sleepless) © My sleep is greatly disturbed (3-5 hrs sleepless) © My sleep is completely disturbed (5-7 hrs sleepless) Section 10: Recreation © | am able to engage in all my recreation activities with no neck pain at all © | am able to engage in all my recreation activities, with some pain in my neck © | am able to engage in most, but not all of my usual recreation activities because of pain in my neck © | am able to engage in a few of my usual recreation activities because of pain in my neck © | can hardly do any recreation activities because of pain in my neck © | can't do any recreation activities at all EFTA00313808

--=PAGE_BREAK=--

Weill Cornell Medicine Thank you for choosing Weill Cornell Physicians for your health-care needs. The following is our payment policy which we require you to read and sign prior your visit(s). Patients have many different types of insurance and payment options for services rendered. Also, not all physicians in the practice accept the same type of insurance. To ensure that we have accurate information to process your claim, we will make a copy of your medical insurance and/or Medicare card at the time of your appointment. You are required to inform us immediately of any changes in demographic information or medical insurance information. Patients without medical insurance are required to pay in full at time of service. We understand that financial hardships may affect your ability to pay in full. We will always do everything we can to work with you. Please ask to speak to our Site Manager to discuss a satisfactory arrangement, Pi You must present your insurance card, and if applicable, your insurance referral form, at every visit. We will submit bills directly to your insurance company for payment on your behalf. Patients without insurance cards or proper referrals will be asked for full payment at time of service. All co-pays, deductibles and non-covered services will be collected at time of service. If — provider does not participate in your insurance plan, you are responsible for payment of all charges at the time of service. We can submit the claim directly to your carrier or a claim can be mailed to you. Payment in full is due at the time of service for all non-medically necessary services and/or cosmetic services. Us: treatment for your patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. For your convenience, the following payment methods are accepted: Cash, personal check, Visa, MasterCard, American Express, Discover Ihave read the policy, I understand and agree to it. _JAN-13 2011p | ee Patient Signature Date EFERES JAnl. 1+ Patient Print Date \) EFTA00313809

--=PAGE_BREAK=--

[ Weill Cornell Physicians \i ry Cy, a Notice of Physician Non-Participation in Your Health Plan Dear Patient, You are scheduled for a visit today with a Weill Cornell Physician that does not participate with your health plan. By signing this document you acknowledge that the provider does not Participate in your health plan and therefore this and any other visits or services from this provider may result in costs not covered by your health plan. If you agree to receive healthcare services from this provider, you are entitled to request an estimate of the physician charges for the anticipated services associated with this visit or any planned procedure. Many Weill Cornell Physicians Participate in various health plan networks, although not every physician Participates in every plan. You can find a list of the plans in which each physician participates by searching their name here: http://weillcornell.org/ under the tab “insurances”. By providing your signature below, you acknowledge that you have agreed to visits with a non- participating provider. esearch JAN 1,308 Signature of Patient or Patient’s Representative EFTA00313810

--=PAGE_BREAK=--

Weill Cornell Medical College (WCMC) Privacy Office Forms Authorization To Disclose Health Information Via E-Mail Patient Name: J CEE REN) EPsteml MRN#: Sweet 4 Easy FIST ST. Dos: city: NJ st: NY zip JOOD\ Phone: This authorization covers Protected health information (PHI) disclosed by Weill Cornell Medical ‘allege (WCMC) eerie {0 @ patient or a patient's representative through e-mail communication It expires when the need to communicate via @-mail is no longer necessary, when the patient changes his/her e-mail address, or if the patient revokes it. Fo ben cnmatanas 1 amuttvor*tssemnamnsenssetscecnesnseetesenseensinsseasneseentessccnmusstesttneettonsaasssscesseeensen serene To be completed by Patient or patient's representative: named patent ving totem ofthis form is authorization for WCMC to disclose the heath information ofthe above: named patient via e-mail. It also confirms my understanding that: . heat informatie a et considered secure. There is the possibilty of re-dieclosure of the personal . Once transmitted, | am responsible for safeguarding the information | receive . Privacy Ofte a evn ins 2uttorization at any time before information is disclosed by submiting tothe rer acy Office a WCMC Revocation of Release of Medical information Fenn # etca nes A revocation will Ter apbly to information that has already been released as a result ofthis authorizaten . If | am communicating via e-mail about someone else, | attest that | am responsible for that person's care or . WEMC will not condition treatment or payment upon receipt of an authorization . ‘ | The e-mail address | wish to use is: eS iP ~______ Patient?Representative Signature Wan 1420 If the patient listed above is a minor or is unable to sign, and you are a parent, legal guardian, or personal “ereseniave who wil use e-mail to communicate about tis patient, please sign above and complete te folowing To be completed by WCNC: Name of WCMC Party (please print): ——— WCMC e-mail: a WCMC, please indicate date completed: ——_ retain a copy of this fequest in the Patient's file, and provide a copy of the original to the requestor P00268 Page 1 of 1 Eff: 1/14/05 FM Auth Email 090115 Rev: 10/1/07 Rev: 1/15/09 EFTA00313811