New Patient Intake Paperwork

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New Patient Intake Paperwork Dr. Carl Balog, MD Medical Director Physician & Surgeon Board Certified Medicine Joseph Knaus, NP David Walker, NP Page 1 of 3 Your completed intake paperwork helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best care possible. Please take your time and inquire at our front desk or call (503) 238-7246 if you have any questions or are unsure how to complete any section of this form. Patient Information Today's Date Your Name Gender: Male Female SSN Address City Drivers Lic. # State Oregon Mothers Maiden Name State Zip Code Email Is the above address also your mailing address? Yes No If no, please fill in your mailing address below. Your Name Marital Status Married Single Divorced Widowed Other, Please Specify Date of Birth, Age, Height, Weight Address Month Age City State Day Height Zip Code Year Weight (lbs.) Preferred Home Work Mobile Emergency Contact Information Check if okay to leave confident messages at this number Secondary Home Work Mobile Check if okay to leave confident messages at this number Name Relationship Primary Language: English Spanish Other, Please Specify Race: American Indian or Alaskan Native Asian or Pacific Islander Black White Decline to Report Ethnicity: Hispanic Non-Hispanic Decline to Report Referral and Physician Relationships Who is your Primary Care Physician (PCP)? Who is your Surgeon (if applicable)? Were you referred to Portland Pain and Spine by another Physician? Yes No If yes, whom? If no, how did you hear about Portland Pain and Spine (Check all that apply)? Family Friend Insurance Co. Facebook Twitter Google+ Our Website Other, Please Specify PCP TV Radio New Patient Intake Form - Rev 1.0.0 12/2013 12672 NW Barnes Road Suite 100 Portland, Oregon 97229 : 503 238 7246 Fax: 503 274 7248 www.pdxpainandspine.com

Health Care Coverage Dr. Carl Balog, MD Medical Director Physician & Surgeon Board Certified Medicine Check the following sources of medical coverage that apply to you for this current pain complaint(s) Joseph Knaus, NP David Walker, NP Page 2 of 3 Private Insurance State Medicaid Worker's Compensation Medicare Self Pay Automobile Insurance Primary Insurance Plan Payer (e.g. BC/BS) Group Number Plan Policy/ID Number Who is the insurance policy holder for your primary insurance? Self Spouse Child Other Complete this box if you are not the policy holder for your primary insuanrance Policy Holder Name Policy Holder Gender Policy Holder Date of Birth Address Male Female Month City State SSN Day Zip Code Employer Year Secondary Insurance Plan (if any) Payer (e.g. BC/BS) Group Number Plan Policy/ID Number Who is the insurance policy holder for your primary insurance? Self Spouse Child Other Complete this box if you are not the policy holder for your secondary insuanrance Policy Holder Name Policy Holder Gender Policy Holder Date of Birth Address Male Female Month City State Oregon SSN Day Zip Code Employer Year Worker's Compensation Claim Information Complete this section only if your visit today is related to a Worker's Compensation Claim Company You Worked For at Time of Claim Worker's Comp Co. Claim Number Agent Name Number Fax Number Briefly Describe the Incident Causing Claim Number Date of Initial Injury New Patient Intake Form - Rev 1.0.0 12/2013 12672 NW Barnes Road Suite 100 Portland, Oregon 97229 : 503 238 7246 Fax: 503 274 7248 www.pdxpainandspine.com

Dr. Carl Balog, MD Medical Director Physician & Surgeon Board Certified Medicine Joseph Knaus, NP David Walker, NP Preferred Pharmacy Information Page 3 of 3 Pharmacy Name Address City State Zip Code Employment Status Employed Unemployed Retired Disabled Employer Occupation HIPAA/Who Can We Share Your Records With (i.e. family, spouse, etc) I authorize my medical records to be shared with the following individuals: Name Name Relationship Relationship Signed By Date PRINTED NAME Disclosure Dr. Carl Balog has a vested interest/ownership in Cornell Surgery Center, LLC and Mt. Scott Surgery Center, LLC. By signing below I acknowledge I have been informed of this relationship. Signed By Date PRINTED NAME New Patient Intake Form - Rev 1.0.0 12/2013 12672 NW Barnes Road Suite 100 Portland, Oregon 97229 : 503 238 7246 Fax: 503 274 7248 www.pdxpainandspine.com

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