Welcome to Verst Spine Care David B. Verst, M.D

Welcome to Verst Spine Care David B. Verst, M.D.

Fellow of the American Academy of Orthopedic Surgery

Diplomat of the American Board of Orthopedic Surgery

Philosophy

Verst Spine Care is a specialized orthopedic practice for comprehensive spine care. The practice is recognized for the highest level of technical expertise in complex surgical interventions and conservative spine care management. The practice pledges to provide the best personalized quality patient care.

· Services Comprehensive Spine surgery – Cervical, Thoracic, Lumbar

· Artificial Disc Replacement

· Reconstruction

· Trauma

· Infections

· Tumors

· Deformity/Scoliosis

· Coccygectomy

· Sacroiliac Fusion

· Complex Revisions

· Workers’ Compensation Cases

· Independent Medical Exams

· Impairment Ratings

· Patient Education

· Conservative Spine Management

· Consultations and Second Opinions

· Legal Review

Appointments

Patients may contact our business office during business hours: Mond-Thurs 8:30am - 4:30pm and Fri 8:30am – 3:00pm to schedule appointments for Hailey, Twin Falls or Gooding locations. Please call to cancel appointments 24 hours in advance. If you request medical records be sent to other individuals, you will be required to sign a release form. Please contact Michele at 208-788-7779 regarding appointments and medical records.

Financial Information

Payments are due at the time of service. Verst Spine & Orthopedic Care submits claims to most insurance carriers for services provided.

We do not bill auto insurance carriers For more information regarding third party liability billing, please contact our billing specialist. We accept cash, checks, Visa and MasterCard. Any portion of your bill not covered by your insurance carrier is your responsibility. We bill monthly and balances are due upon receipt of the statement unless other arrangements have been made. Please contact Elaine, our billing and insurance specialist, with any questions at 702-896-9677.

Prescriptions/Medications

Dr. Verst may prescribe medications for a limited time as part of your care. Please contact your pharmacy for any medication refills. Refill requests are taken during business hours, Mon – Thurs 8:30 – 4:00 pm. Calls on Friday should be made by 2:00pm. Please allow at least 24 hours for refill requests to be processed. Medications are not refilled on weekends. For questions regarding medications, please contact Evelyn, Dr. Verst’s assistant.

Confidentiality

The staff at Verst Spine care is committed to maintaining your confidentiality. Our practice complies with HIPAA (Health Insurance Portability and Accountability Act of 1996) and state laws. Patients are provided a copy of our privacy statement.

Clinic Locations

· Hailey 15 W. Galena St.

· Twin Falls Renaissance Plaza

706 N. College Rd. Suite A.

· Gooding North Canyon Medical Center-Specialty Clinic

267 North Canyon Drive

New Patient Questionnaire Date______

Name______Date of Birth______Age___

Height______Weight______Occupation______

Who referred you to Verst Spine & Orthopedic Care? Name______

* Physician * Chiropractor * Physical Therapist * Friend/Family * Patient

Briefly describe your injury and/or pain:

______

Was this the result of an injury at work or a motor vehicle accident? * Yes * No

If yes, please explain.______

How did your current episode begin? * Suddenly * Gradually

Date symptoms began ______

If you suffered an injury, where did it occur? * Work injury * Motor vehicle accident * Other

Current symptoms are: * Worsening * Staying the same * Getting better

Which hurts you more? * back ____% back pain + * legs ____% legs pain = 100%

Which hurts you more? * neck ____% neck pain + * arm ____% arm pain = 100%

Please circle the ONE number which best describes your current pain level.

0 = no pain, 10 = worst pain imaginable

Severity of: back pain no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain

leg pain no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain

Severity of: neck no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain

arm pain no pain 0 1 2 3 4 5 6 7 8 9 10 worst pain

Duration of: back pain * occasional * intermittent * frequent * constant

leg pain * occasional * intermittent * frequent * constant

neck pain * occasional * intermittent * frequent * constant

arm pain * occasional * intermittent * frequent * constant

Please mark any of the following symptoms which you have experienced recently:

* leg weakness * weight loss * bowel retention

* arm weakness * fever, chills, night sweats * bladder retention

* bladder incontinence * sleeping difficulties

* bowel incontinence

Circle a number to indicate how much of a problem you are having with each of the following:

Anxiety none 0 1 2 3 4 5 6 7 8 9 10 worst

Depression none 0 1 2 3 4 5 6 7 8 9 10 worst

Irritability none 0 1 2 3 4 5 6 7 8 9 10 worst

Insomnia none 0 1 2 3 4 5 6 7 8 9 10 worst

Please mark the effect of the following activities on your pain:

Sitting * increases * decreases * no change

Standing * increases * decreases * no change

Rising from sitting * increases * decreases * no change

Bending forward * increases * decreases * no change

Bending backward * increases * decreases * no change

Walking * increases * decreases * no change

Lying on back * increases * decreases * no change

Lying on stomach * increases * decreases * no change

Driving * increases * decreases * no change

Cough/Sneeze * increases * decreases * no change

Have you had previous neck or back surgery? * Yes * No

If yes, Date of Surgery Type of surgery Surgeon name % Improvement

______

Additional prior treatments:

* Physical Therapy * Chiropractor * Acupuncture * Bracing * TENS

* Medications * Narcotic medications * Other ______

Have you had previous spinal injections? * Yes * No

If yes, Date of Injection Type of injection % Improvement

______

Previous Back or Neck History

Have you had any previous back or neck symptoms severe enough to seek professional help other than the current problem? * Yes * No

If Yes, please explain ______

Were any of these previous episodes the result of a work injury or motor vehicle accident?

* Yes * No If Yes, please explain______

Please list all medications you are presently taking including over the counter drugs:

Drug Name Dosage

______

DRUG ALLERGIES/REACTIONS______

Functional Rating Index: Circle the number which describes your condition right now.

Pain Intensity: No pain Mild pain Moderate pain Severe pain Worst possible pain

0 1 2 3 4

Sleeping None Mild Moderate Great Total

Disturbance: 0 1 2 3 4

Personal Care: No pain Mild pain Moderate pain Severe pain Worst possible pain

0 1 2 3 4

Travel None/long trip Mild/long trip Moderate/long trip Moderate/short trip Severe/short trip

Pain: 0 1 2 3 4

Work Usual + extra Usual + no extra 50% of usual 25% of usual Can’t work

Ability: 0 1 2 3 4

Recreation All activities Most activities Some activities A few activities Can do no activities

Ability: 0 1 2 3 4

Pain Frequency: No pain Pain 25% of day Pain 50% of day Pain 75% of day Constant pain

0 1 2 3 4

Lifting None Some/heavy weight Some/moderate weight Some/light weight Pain any weight

Pain: 0 1 2 3 4

Walking: No pain Pain after 1 mile Pain after ½ mile Pain after ¼ mile Pain with all walking

Pain: 0 1 2 3 4

Standing None/several hours Some/3 hours Pain after 1 hour Pain ½ hour Pain/any standing

Pain: 0 1 2 3 4

Add all numbers for Total Score ______

Work Status:

* Currently working * Student * Disabled and/or retired because of my back/neck problems

* Unemployed * Disabled, due to a health problem not related to my back or neck

* Homemaker * On paid leave

* Retired (not due to health) * If not working, date last working______

Review of Systems

Please fill in the box next to your current symptoms.

Skin: * rashes * psoriasis * bruise easily * abnormal lumps * painful breasts

Eyes: * visual loss * double vision * wear glasses

Ears: * decreased hearing * ringing in ears

Nose: * sinus problems * breathing problems

Throat: * sore throat * hoarseness * snoring

Cardiovascular: * palpitations/irregular heartbeat * heart murmur/rheumatic fever * chest pain

* pacemaker

Respiratory: * shortness of breath * wheezing * cough/sputum production

Gastrointestinal: * weight loss * abdominal pain * nausea/vomiting * diarrhea

* constipation * blood in stool * loss of bowel control

Musculoskeletal: * fractures/sprains * osteoporosis * joint swelling

Genitourinary: * blood in urine * increased frequency of urination * painful urination

* loss of bladder control * kidney stones

Endocrine: * enlarged thyroid/goiter * excessive thirst/appetite * diabetes______(type)

Neurologic: * headache/migraine * dizziness * convulsions/seizures * loss of consciousness

Emotional: * depressed * anxious * Irritable

* victim of physical/emotional/sexual abuse

* Major stress or stressful event in past year

* Other ______

List any Non-back/neck surgeries:

surgery______approximate date______

Past Medical History:

Please mark any of the following medical problems you have had at any time in the past.

* Arthritis * Abnormal bleeding tendencies * Hepatitis

* Ulcerative Colitis * Kidney/bladder infections * Stroke

* Psoriasis * Kidney Stones * Asthma

* Tuberculosis * Prostate problems * Seizures

* Cancer ______(type) * Diabetes * Claustrophobia

* HIV positive * Heart Disease/Heart attack * Migraines

* Anesthetic difficulties * High Blood Pressure * Mental Illness

* Depression * Anxiety * Metal in body ______

* Pacemaker * Other ______

Past Family History:

Please mark conditions in your family.

* Cancer ______* Arthritis

* Malignant Hyperthermia * Diabetes

* Back pain * Heart Disease

* Abnormal bleeding tendencies * Anesthetic difficulties

* Stroke * Other ______

Marital Status: check all that apply Education:

* Married * GED

* Divorced * Graduated from high school

* Widowed * College

* Single * Other ______

* Have children

Personal History:

Do you smoke cigarettes, cigars or chew tobacco? * No * Yes

I smoke cigarettes ______# packs/day or number of cigars * Chew tobacco _____# tins/day

* Used to use tobacco but quit ______(when)

Do you drink alcoholic beverages?

* No * Rarely * 1-2 times per week * Daily

Primary Care Physician: Dr.______City______

Cardiologist: Dr. ______City______

Patient Signature______Date______

PATIENT INFORMATION Date______

How will you be paying for this visit? Cash Check Credit Card Insurance/Copay

Last Name ______First______Middle______

Perm. Mailing Address______

City______State ____ Zip ______

Local Address (if different) ______

City ______State____ Zip ______

Home Phone ( ) ______Visiting Phone ( )______

Cell Phone ( ) ______

Social Security # ______Birthdate ______Sex ______

Relationship to insured? ______(self, spouse, child, other).

Who can we thank for your referral? ______

RESPONSIBLE PARTY INFORMATION If the patient is a minor

Last Name ______First______Middle______

Perm. Mailing Address ______City______State ___ Zip ______

Local Address (if different) ______City ______State___ Zip ______

Home Phone ( ) ____ Other Phone ( )______

EMPLOYER INFORMATION

Name ______Phone ( )______

Address ______

Occupation ______

INSURANCE INFORMATION

Medicare # ______Relationship to insured ______

Insurance Co. Name ______

ID # ______Group # ______

EMERGENCY INFORMATION

Please give us the name of a parent, guardian, relative or friend NOT living with you.

Name ______Phone ( )______

Address ______City ______State __ Zip______

Relationship ______

Verst Spine & Orthopedic Care

Patient Agreement

I consent to treatment by David B. Verst, M.D. at Verst Spine & Orthopedic Care, including any x-ray examination, laboratory procedures, anesthesia, medical or surgical treatment rendered to me, my minor dependents, or minor children over whom I have legal or temporary guardianship, under the physician’s general or special instructions.

I hereby authorize Verst Spine & Orthopedic Care and its physician to furnish insured’s insurance company all information which said insurance company may request concerning my medical treatment. I hereby authorize Verst Spine & Orthopedic Care and its physician permission to discuss my medical treatment with other health professionals for the purpose of medical prescriptions, operations and payment.

I hereby assign Verst Spine & Orthopedic Care and its physician all money to which I am entitled for expense relative to the services performed from time to time, not to exceed my indebtedness to Verst Spine & Orthopedic Care and its physician and authorize direct payment to Verst Spine & Orthopedic Care and its physician for those billed charges.

I understand that any money received from the above-referenced insurance company over and above my indebtedness will be refunded to me when my bill is paid in full.

I understand that I am personally responsible to Verst Spine & Orthopedic Care and its physician for payment of all charges incurred by me regardless of whether they are covered by insurance. I further understand that Verst Spine & Orthopedic Care may look directly to me for full payment of all charges incurred by me, even if billings have been submitted to my insurer for payment by Verst Spine & Orthopedic Care.

I am also requesting that the clinic extend credit to me for any charges, if requested before appointment, I will not be paying at the time of service. In requesting credit, I hereby authorize Verst Spine & Orthopedic Care and its physician to run a credit report from any credit bureau for purposes of evaluating this and future requests for credit on my behalf.

In the event Verst Spine & Orthopedic Care turns my account over for collection or retains an attorney to enforce its right to payment, I agree to pay all of Verst Spine & Orthopedic Care’s reasonable collection fees and costs, whether or not litigation is commenced. This provision shall extend to attorney’s fees and costs incurred on appeal judgment or order entered by any court adjudication rights or remedies created by or arising out of this contractual relationship; to the extent necessary, this provision shall not be merged into but shall survive entry of judgment in any action upon this agreement.