Were you referred to our clinic by another physician? ! Yes ! No

⌦ If so, whom?⌦ If not, how did you hear about us? ! Insurance Company ! Family ! Friend

! Google Search ! Bing Search ! i______________________________

! ! Other Website

INSURANCE CARRIER: __________________________________ All patients are entitled to have a chaperone present in the consulting room where they feel one is required. This chaperone may be one of our staff members, a family member or friend.

YES, i would like a chaperone in the exam room.

Patient Information

Name:Social Security Number: _________________________

Date of Birth:

Street:

______________________________

City/State/Zip:

Physical Address Same as Mailing? ! Yes ! No If not

Preferred Phone:

Secondary Phone:

Email:

Emergency Contact Name:

Phone:

Relationship:

Marital Status: ! Married ! Single ! Divorced ! Widowed ! Other Race: ! American Indian or Alaskan Native ! Asian or Pacific Islander ! Black ! White

! Refuse to Report

Ethnicity: ! Hispanic ! Non-‐Hispanic ! Refuse to ReportPrimary Language: ! English ! Spanish ! Other

Referral

Insurance

200 WEST WARDLOW ROAD LONG BEACH CA 90807 P: (310) 854-0283 F: (310) 854-0284

NICHOLAS FULLER MD

NICHOLAS S. FULLER, M.D. 200 WEST WARDLOW ROAD

LONG BEACH CA 90807(310) 854-0283

PERSONAL HEALTH INFORMATION (PHI) COMMUNICATION

Dear Patient:

To respect your privacy, please tell us which of the following numbers we should call to communicate with you regarding appointment reminders, follow up, results, etc. Only list the phone numbers y o u w i s h f o r u s t o c a l l .

Please specify if a message can be left on an answering machine or voice mail with a spouse or significant other or with another designated person.

☐ HOME #: ____________________________ Message Y N☐ CELL #: ___________________________ Message Y N☐ WORK #: ___________________________ Message Y N☐ Email: ___________________________ Message Y N

PLEASE PROVIDE A PHONE NUMBER WHERE WE MAY REACH YOU:

My PHI may be communicated to:

Do not communicate my PHI to:

Name:

Signature: Date:

Screening for Aerosol Transmissible Diseases (ATD)In compliance with California OSHA Title 8, Section 5199, health care facilities must prescreen patients for aerosol transmissible diseases.

Do you have (circle): History of Tuberculosis or symptoms of Tuberculosis (Productive cough, Bloody Sputum, Fever, Malaise, Night Sweats, Fever Unexplained Weight Loss).

If not please initial: No_________

Do you have (circle): Flu and other Aerosol Transmissible diseases, including pertussis, measles, mumps, rubella, chicken pox, meningitis (Body Aches, Runny Nose, Sore Throat, Nausea, Vomiting, Diarrhea, Fever & Respiratory Symptoms, Severe Coughing Spams, Painful-swollen Glands, skin Rash-blisters, stiff Neck)

If not please initial: No_________

Chronic Respiratory Diseases (NOT ATD’s, and not considered Infectious) do not disqualify a patient from treatment. Do you have (circle): Chronic upper airway cough syndrome “postnasal drop,” Gastro esophageal reflux disease (GERD), chronic obstructive pulmonary disease (COPD), Bronchitis, Emphysema, Allergies, Asthma.

If not please initial: No_________

_______________________________________ _____________________Patient Signature Date

Health Changes Signature Date

Patient Name: ______________________________________

200 WEST WARDLOW ROAD LONG BEACH CA 90807 P: (310) 854-0283 F: (310) 854-0284

HIPPA MEDICAL INFORMATION RELEASE FORM HIPPA is the Health Insurance Portability and Accountability Act, a federal law that:

● Protects the privacy of a patient’s personal and health information● Provides for electronic and physical security of personal and health information● Simplifies billing and other transactions

Authorization for Use or Disclosure of Protected Health Information

I, ____________________________________________, _______________________ hereby authorize Patient Name Date of Birth

Xcell Surgery Center to use or disclose my health information as Follows (check those that apply):

❒ Use the following protected health information, and/or❒ Disclose the following protected health information to:____________________________________________________________

Name, address &phone number of Entity to receive information Specifically describe the information to be used or disclosed:

❒ All health information pertaining to any medical history and treatment received❒ Only the following records or types of health information (including any dates)

! Consultation / Operative Reports! Diagnostic Imaging Reports and Films (X-Ray, Ultrasound, CT, MRI, etc) ! EMG and Nerve Conduction Study Reports! Complete Medical Record! OTHER: ____________________________________

The Notice of Privacy Practice allows protected health information to be used or disclosed for the following specific purpose(s): ● Treatment● Payment● Operations (teaching, medical, staff/ Peer review, legal, auditing, customer service, business management)● Public health and safety reporting● Other reporting required by government, such as in cases of abuse● Subpoenas, Trials and other legal proceeding● Workers’ compensation programs

This Authorization shall be in effect and expires:______________________________________________Specify date or event that relates to the patient or the purpose of the use or disclosure- not to exceed 24 months.

I understand that I have the right to revoke this authorization, in writing, signed by me or on my behalf at any time by sending such written notification to: NICHOLAS FULLER/XCELL SURGERY CENTER

200 WEST WARDLOW ROADLONG BEACH CA 90807

I understand that a revocation is not effective to the extent that Xcell Surgery Center has relied on the use or disclosure of the protected health information. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. Xcell Surgery Center will not condition my treatment, payment, enrollment in health plan, or eligibility for benefits ( if applicable) on wether I provide authorization for the requested use or disclosure. I understand that i have the right to:

● Inspect or copy the protected health information to be used or disclosed as permitted under federal law, or state law to the extent the state law provides greater access rights.

● Refuse to sign this authorization● Receive a copy of this authorization

____________________________________________________________________________________Print Name of individual or personal representative Date:

____________________________________________Signature of individual or personal representative

__________________________________________________________________________________Witness Signature Date:

200 WEST WARDLOW ROAD LONG BEACH CA 90807 P: (310) 854-0283 F: (310) 854-0284

NICHOLAS S. FULLER, MD

PERSONAL INJURY LIEN

ATTORNEY: _____________________________________________________________________________________________

Patient/ Client Name: _________________________ D.O.I. _________________ RE: Medical Reports and Doctors Lien

I do hereby authorize the above doctor to furnish you , my attorney, with a full report of his examination, diagnosis, treatment, prognosis, etc. of myself in regard to the accident in which I was involved.

I hereby authorize and direct you, my attorney, to pay directly to the said doctor such sums as may be due and owing him for medical services rendered to me both by reason of this accident and by reason of any other bills that are due his office also to withhold such sums from any settlement, judgement or verdict as may be necessary to adequately protect said doctor. I hereby, further give a lien on my case to said doctor against any and all proceeds of any settlement, judgement or verdict which may be paid to your, my attorney, or myself as the result of injuries for which I have been treated or injuries for which I have been treated in connection therewith.

I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered to me and that this agreement is made solely for said doctor’s additional protection and in such consideration of his awaiting payment. I further understand that such payment is not contingent on any settlement, judgement or verdict by which I may eventually recover said fee.

DATE: _________________________ PATIENT’S SIGNATURE:_________________________

The undersigned, being attorney of record for the above patient, does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgement or verdict as may be necessary to adequately protect said doctor above named.

DATE: _________________________ ATTORNEY’S SIGNATURE:_________________________

Instructions for Attorney’s office: Please date, sign and return one copy to the doctor’s office immediately. Keep one copy for your records.

200 WEST WARDLOW ROAD LONG BEACH CA 90807P: (310) 854-0283 F: (310) 854-0284

PERSONAL INJURY LIEN

Attorney: _______________________________ Phone: _______________________________

Fax:________________________________

Patient/ Client Name: _________________________ D.O.I. _________________

RE: Medical Reports and Doctors LienI do hereby authorize the above doctor to furnish you, my attorney with a full report of his examination, diagnosis, treatment, prognosis, etc. of myself in regard to the accident in which I was involved.

I hereby authorize and direct you, my attorney, to pay directly to the said doctor such sums as may be due and owing him for medical services rendered to me both by reason of this accident and by reason of any other bills that are due his office also to withhold such sums from any settlement, judgement or verdict as may be necessary to adequately protect said doctor. I hereby, further give a lien on my case to said doctor against any and all proceeds of any settlement, judgement or verdict which may be paid to your, my attorney, or myself as the result of injuries for which I have been treated or injuries for which I have been treated in connection therewith.

I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered to me and that this agreement is made solely for said doctor’s additional protection and in such consideration of his awaiting payment. I further understand that such payment is not contingent on any settlement, judgement or verdict by which I may eventually recover said fee.

DATE: _________________________ PATIENT’S SIGNATURE:_________________________

The undersigned, being attorney of record for the above patient, does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgement or verdict as may be necessary to adequately protect said doctor above named.

DATE: _________________________ ATTORNEY’S SIGNATURE:_________________________

Instructions for Attorney’s office: Please date, sign and return one copy to the doctor’s office immediately. Keep one copy for your records.

200 WEST WARDLOW ROAD LONG BEACH CA 90807P: (310) 854-0283 F: (310) 854-0284

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE

USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS

INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

NICHOLAS FULLER MD/XCELL SURGERY CENTER understands and agrees that patient confidentiality can be an integral part ofpatient care. Under the Health Insurance Portability and Accountability Act (commonly, HIPAA), all health care providers must

maintain as confidential your protected health information, or PHI. Your PHI can include your name, address, social security number,

email address, telephone number, date of birth, driver’s license number, and medical record number. Health care providers must also

provide patients with notice of the legal duties incumbent upon

health care providers and their privacy practices so that the health care providers avoid any accidental or inappropriate disclosure of your

PHI.

In February 2009, The American Recovery Reinvestment Act (ARRA or more commonly, the “Stimulus Bill”) made some significant

modifications to the HIPAA Privacy and Security Rules dealing primarily with the protection of your PHI in all media (meaning paper files

and electronic storage). In addition, the Stimulus Bill introduced some new terminology – “Personally Identifiable Information” or “PII”

along with penalties and mitigation associated with any violations and/or breaches of PHI or PII.

Personally Identifiable Information (again, the PII) is defined as any patient’s first name or first initial and the last name in combination

with any one or more of the following data elements belonging to that patient: social security number; driver’s license number of ID card

number, account number or credit/debit card number in combination with any required security code or access code or password that

would permit access to the patient’s financial account.

NICHOLAS FULLER MD/XCELL SURGERY CENTER uses health information about you for treatment purposes, to obtain payment fortreatment it has provided to you, for internal administrative purposes, and to evaluate the quality of care you receive. In addition, as part

of your ongoing treatment, health information may be shared with other health care providers (for example, certain medical specialists)

to whom you are referred or from whom you were referred to. Such

information may be shared by paper mail, electronic mail, facsimile or other methods.

Further, NICHOLAS FULLER MD/XCELL SURGERY CENTER may disclose your PII (in whole or in part) without your authorizationunder certain circumstances. For example, subject to specific requirements, we may disclose your PII without your authorization for

public health purposes such as reporting communicable diseases, birth, death, injury, child abuse or neglect; for auditing purposes; for

research studies; for worker’s compensation claims; and for emergencies. We will also provide information when required to do so by

law enforcement authorities or by court authorities. Contact with you may also take place in the form of appointment reminder,

prescription refills, test results, etc.

When other situations arise we will ask you for your written authorization before using or disclosing any of your PII. If you choose to sign

an authorization to disclose some or all of your PII, you may later request to revoke either all or part of the authorization.

As the patient, you have the right to see and receive a copy of all information that is contained in your medical record

(chart) at this office, with the following exceptions: psychotherapy notes; information compiled in reasonable anticipation

of civil, criminal or administrative litigation or enforcement proceedings; and protected health information if it is subject to

protection under other applicable law. If NICHOLAS FULLER MD/XCELL SURGERY CENTER denies your right of access,you are entitled to have that determination reviewed if the reason for the denial was one of the following: a health care professional has determined that access to the information is likely to endanger the life or safety of you or another person;

or the protected health information refers to another person and access to the information is likely to cause harm to that

person. If NICHOLAS FULLER MD/XCELL SURGERY CENTER denies your right of access, you will not be entitled to havethat determination reviewed if the reason for the denial was one of the following: the protected health information is

excepted from the right of access under applicable law; or the protected health information was obtained from someone

other than the health care provider under a promise of confidentiality.

NICHOLAS FULLER MD/XCELL SURGERY CENTER shall have thirty (30) days to act on a written request for access to your medical records. Any written request from you will be responded to in writing from

NICHOLAS FULLER MD/XCELL SURGERY CENTERand we will provide you with the anticipated date by which we will complete action on your request. If access is denied, we will inform you in writing of the

basis or bases for the denial.

If you believe that information contained in your medical record is incorrect or if important information is

missing, you have the right to request that a correction be made to the information in your record. This

request must be submitted in writing and must include a reason to support the request. XCELL SURGERY CENTER must act on such a request within 60 days of our receipt of your request. The acceptance or denial of a request to amend or correct your medical record will follow the same process as described

above concerning access to your medical record.

You have the right to request and receive a written list of certain disclosures of your health information,

made after April 14, 2003. You may ask for disclosures we made up to six (6) years before your request.

This listing will include the date of the disclosure, the name (and address, if available) of the person or

organization receiving the information, a brief description of the information disclosed and the purpose of

the disclosure. NICHOLAS FULLER MD/XCELL SURGERY CENTERis not required to include on the list of disclosures those disclosures which were made: for purposes of treatment; for purposes of billing and

collection of payment for your treatment; for our health care operations; in response to a prior request

from you that was authorized by you or which was made to individuals involved in your care or

treatment; or as otherwise allowed pursuant to applicable law. A first request of disclosures will be

provided to you free of charge; a subsequent request made within 12 months of a first may result in a

reasonable charge to you for such service.

You have the right to request that we limit our use and disclosure of your health information for treatment,

payment and health care operations. You also have a right to request a limit on the health care

information we disclose about you to someone who is involved in your care or the payment of your care,

for example, a family member or friend. We are not required to agree to such request however

NICHOLAS FULLER MD/XCELL SURGERY CENTER agrees to such a request, we must follow the agreed upon restriction. You may cancel the restriction at any time and we, too, may cancel the restriction at any

time as long as we notify you of the cancellation.

You have the right to complain about any perceived privacy violations or if you disagree with a decision

we made about access to your medical records. All complaints, concerns or questions should be

submitted in writing to our office. You may contact

200 WEST WARDLOW ROADLONG BEACH CA 90807

Tel. 310 854-0283

Fax 310 854-0284

We are required to obtain your written acknowledgment that you have read this notice, been given the

opportunity to ask questions about this notice, and been given a copy of this notice.

PLEASE SIGN AND RETURN THE ACKNOWLEDGMENT ACCOMPANYING THESE PRIVACY

PRACTICES WHICH INDICATES THAT YOU HAVE READ THIS NOTICE OF PRIVACY PRACTICES,

THAT YOU HAVE BEEN GIVEN THE OPPORTUNITY TO ASK QUESTIONS ABOUT IT, AND THAT

YOU HAVE BEEN GIVEN A COPY OF THE NOTICE OF PRIVACY PRACTICES IF YOU WANT ONE.

NOTICE OF PRIVACY PRACTICES

Acknowledgement of receipt of Notice of Privacy Practices

I have received NICHOLAS FULLER MD/XCELL SURGERY CENTER Notice of Privacy Practices, and I have been given theopportunity to review them and ask questions about them.

Signature:

Print Name:

Date:

1

List your pain according to severity: #1. __________________ #2. __________________ #3. __________________

Pain distribution: Head: _______% Left: _______ Right: ______ Neck: _______% Left: _______ Right: ______ Shoulder: _______% Left: _______ Right: ______ Arms: _______% Left: _______ Right: ______ Hands: _______% Left: _______ Right: ______ Mid back: _______% Left: _______ Right: _______ Low back: _______% Left: _______ Right: _______ Buttocks: _______% Left: _______ Right: _______ Thighs: _______% Left: _______ Right: _______ Feet: _______% Left: _______ Right: _______

Height: _____________ Weight: _____________

DATE OF INJURY: PAIN LEVEL ________/10

Age: _____________

2

Describe the events of the accident briefly:

_________________________________________________________________

IF MVA: Were you the driver or passenger? __________________________ Were you wearing a seatbelt? YES NO Did airbags deploy? YES NO After the impact: what happened: ___________________________________ Did any part of your body hit any part of the car or other objects? NO YES __________________________________________________________________

After the incident: Did you lose consciousness? YES NO Momentarily Did the paramedics assess you at the scene? YES NO Did you go to the hospital? NO YES Name of Hospital: _______________ What tests were performed at the hospital? CT MRI X-RAYS OTHER When were you released? __________________________________________ What diagnosis did they give you? ___________________________________

Prior to this accident, did you have any pain or functional limitations? NO YES: ______________________________________________________

WHIPLASH SYMTPOMS: *Headaches? YES No *Memory loss: YES No

*Difficulty concentrating? YES No *Ringing in ears? YES No

3

Physical Limitations: PLEASE BE SPECIFICWhat activities make the pain worse: _______________________________ What daily activities are you not able to do since the accident? _________________________________________________________________ Are you currently working? YES NO What kind of work do you do? ______________________________________ How has the pain interfered with work? _____________________________________________________________________________

Do you have weakness? NO YES Where? Be specific: left/right ________________________________________ Do you have numbness? NO YES Where? Be specific: left or right _____________________________ Do you have problems using your hands? _____________________________

Do you have problems with:

Bowel control: NO YES explain _____________________________________ Bladder control: NO YES explain ___________________________________ Walking: NO YES explain __________________________________________ Balance: NO YES explain __________________________________________

Do you have pain at rest: NO YES Fever: NO YES Night Sweats: NO YES Difficulty with sleep: NO YES (is it because of pain? YES NO) __________________ Anxiety: NO YES (are you on meds YES NO ) Depression: NO YES (are you seeing a psychologist/psychiatrist Yes NO)

Provider Assessments: Doctors you have seen since the accident: ____________________________________ Please indicate what type of doctor they are: _____________________________________________________________________________

Diagnostic Assessments: Imaging you’ve had since accident: MRI CAT SCAN X-ray EMG body part/s: _____________________________________________________

4

Treatments you have tried since accident: Chiropractor: YES NO *did it improve function Y NO* How much pain relief? ________________% for how long? _______________Are you in chiro care now? YES NO

Physical therapy: YES NO *did it improve function Y NO did it relieve the pain? Y NOHow much relief? _______% for how long? ___________________________*Are you in PT now? YES NO ***Did PT teach you exercises? No YES______________________Massage: YES NO *did it help? Y NO * did it relieve the pain? Y NOInjections: YES NO *did it help? Y NO *did it relieve the pain? Y No Areyou exercising at home? NO YES what kind: ______________________Medications: ______________________________________________________

Medical Problems: DO YOU HAVE THE FOLLOWING PLS CIRCLE

Diabetes high blood pressure infectious diseases heart problems kidney problems liver problems asthma heart stents medical problems you have: ________________________________________

Surgeries you’ve had in the past:

List ALL medications you are taking: How much and how often __________________________________________________________________

ALLERGIES: Medication you are allergic to: ______________________________________ What is your reaction to the medicine? ______________________________

SOCIAL HISTORY: Are you married? YES NO DIVORCED SINGLE # Children: _________________________

HABITS: Tobacco use: NO YES: how many cig/day? __________________ Alcohol use: NO YES: how much: ___________________ Recreational drug use: NO YES: _____________________

REVIEW OF SYSTEMS!Mark the following symptoms that you currently suffer from.!

Today's date: ____________ Allergies: ____________________ Reaction:______________________!!CONSTITUTIONAL:!❑ easy bruising ! ❑ swollen/tender lymph nodes! !❑ fevers! ! ❑ unexplained weight gain! ❑ excessive thirst! ❑ difficulty sleeping!❑ Insomnia! ! ❑ unexplained weight loss! ❑ abnormal bleeding! ❑ fatigue!❑ chills!! ! ❑ excessive sweating! ! ❑ tremors! ❑ night sweats!❑ unexplained falls! ❑ low sex drive!!SKIN:!❑ Changes in moles! ❑ rashes! ❑ discoloration! ❑ sores!❑ blisters
❑ lumps/bumps/masses!!HEAD/ EYES/ EARS/ NOSE / MOUTH/ THROAT:!❑ recent visual changes!❑ eye pain ! ! ❑ double vision!❑ headaches!❑ earaches! ! ! ❑ hearing problems! ❑ ringing in ears! ! !❑ nosebleeds! ! ! ❑ dental problems! ❑ recurrent sore throat!❑ sinus problems! ❑ difficulty swallowing! !!CARDIOVASCULAR: !❑ fainting! ! ❑ bleeding disorder! ❑ chest pain! ! ❑ deep vein thrombosis!❑ lightheadedness! ❑ irregular heartbeat! ❑ swelling of feet! ❑ high blood pressure!❑ shortness of breath during sleep!!RESPIRATORY: !❑ shortness of breath on extertion/effort!❑ cough! ❑ wheezing! !❑ shortness of breath at rest! ! ! ❑ pulmonary embolism !!GASTROINTESTINAL:!❑ abdominal cramps! ❑ acid reflux! ❑ constipation! ! ❑ diarrhea! ❑ dark tarry stool!❑ hernia! ! ❑ vomiting! ❑ coffee ground appearance in vomit!!GENITOURINARY:!❑ blood in urine!! ❑ flank pain! ❑ painful urination!❑ increased urination frequency!! ❑ decrease urine flow/frequency/volume!!MUSCULOSKELETAL:!❑ joint swelling! ! ❑ joint pain! ❑ joint stiffness!❑ muscle spasms! !❑ back pain! ! ! ❑ neck pain! ❑ decreased range of motion!!NEUROLOGICAL:!❑ numbness/pain in hands! ❑ dizziness! ❑ numbness/tingling! ❑ seizures!❑ limb weakness! ! ❑ instability when walking! ❑ speech problems! ❑ tremor!!ENDOCRINE:!❑ diabetes! ! ! ❑ hyperthyroid! ! ❑ hypothyroid! ❑ birth control pill use!❑ lack of stamina/energy! ❑ difficulty with erection!❑ darkening of skin!! !PSYCHIATRIC:!❑ suicidal thoughts! ❑ depressed mood! ! ❑ feeling anxious! ❑ stress problems!❑ suicidal planning! ❑ thoughts of violence! ❑ difficulty concentrating!

! ! !

DO YOU HAVE ANY CONCERNS:

Xcell MVA packet for patients.pdfCD8511A5A98757936DECAF278F7B6A1DNOTICE OF PRIVACY PRACTICESI have received INTELLIGENT PAIN SOLUTIONS Notice of Privacy Practices, and I have been given the opportunity to review them and ask questions about them.

DATE: