Welcome to Pain Management Physicians An appointment has been scheduled for your initial evaluation on:

Transcription

1 Welcome to Pain Management Physicians An appointment has been scheduled for your initial evaluation AM/PM. Please arrive 30 minutes prior to your appointment to turn in your paperwork. If you are late for your appointment or you do not have your paperwork, you will have to be rescheduled due to the delay it would cause our clinic. If you cannot make your appointment and you want to reschedule, please give us 48 hour notice so we can get you rescheduled for the earliest available appointment. Please use the following checklist to make sure all of your materials are in order for your initial evaluation. Failure to have ALL of these will result in rescheduling your appointment. I have mailed or hand carried ALL records and radiographic work (x-rays, MRI & CT) about my pain condition to Pain Management Physicians. I have brought all insurance cards and a government issued photo I.D. I have filled out ALL the New Patient Packet prior to my appointment. ** It is the policy of Pain Management Physicians that our physicians will not write for any narcotic pain medications or take over management of routine medications. The initial appointment is for evaluation purposes, and will not consist of procedures or pain medication prescriptions. ** Please keep this information packet. You may find it useful during the course of your treatment. We look forward to treating you at Pain Management Physicians. If you have any questions, please feel free to call our patient coordinator at (334) Thank you. Patient Signature: By signing above, I agree that I have read, understand, and consent to all material, including clinic policies contained in the New Patient Packet. **Official signature(s) will be collected during first office visit.**

2 NEW PATIENT FORM Your Current Age: What is the reason for your visit? Where on your body is your pain located? Does your pain spread? If so, to what other parts of your body? How long ago did your pain begin? Was there an inciting event? (e.g., Is your pain a result of a fall or accident or a MVA) Is your pain the result of a work related injury? If yes, is the case closed or settled? Is your pain interfering with your ability to work? If yes, are you currently involved in a lawsuit or have you retained an attorney? On a scale of 0 to 10 (zero being no pain and ten representing the worst imaginable pain), what number would you assign to your pain on average? Is there any numbness accompanying your pain? Describe your pain. (e.g., sharp, dull, radiating) What relieves your pain? (e.g., medications, heat/ice, massage, stretching) Does your pain interfere with your sleep? Does your pain affect your mood? What makes your pain worse? How frequent is your pain and when does it occur? (e.g., worse in the morning or evening)

3 NEW PATIENT FORM PLEASE PRINT Today s Date: First Name Middle Last Name DOB SSN Male/Female Race Pleace circle ethnicity: Hispanic Non-Hispanic Address Pleace circle marital status: Married Single Divorced Separated Widowed # of Children: Mailing Address City State ZIP Physical Address (If mailing address is a PO Box) Home Phone # Cell Phone # Employer Employer Phone # Employer Address City State ZIP In case of emergency who may we contact? Name Relationship Phone # If married and emergency contact person listed is not your spouse, please give spouse s name and phone #: Name Phone # Is your visit with us related to an injury that you incurred on the job or a motor vehicle accident? If yes, is this visit billed as Worker s Compensation? Primary Insurance Company Policy # Group # Ins. Billing Address City State ZIP Phone # Primary Policy Holder s Name DOB Secondary Insurance Company Policy # Group # Ins. Billing Address City State ZIP Phone # Primary Policy Holder s Name DOB Have you retained an attorney? Please circle highest education level completed: Some High School High School Diploma GED Some College Associated Degree Bachelor s Degree Master s Degree Professional Degree When was your last medication evaluation? By Whom? Who is your Primary Care Physician (PCP)? Phone # Who may we thank for your referral? Phone #

4 NEW PATIENT FORM Have you previously sought help from other pain management physicians? If yes, please name them: Have you participated in physicial therapy? If yes, did your pain improve? Please list all radiographic work up related to your pain (e.g., x-ray, MRI, CT): Are you allergic to any mediation? If yes, please list medication and describe type of allergic reaction: Have you ever been treated by a mental health professional for a psychiatric disorder? If yes, please describe and identify physician who treated you: Patient Signature: Date: **Official signature(s) will be collected during first office visit.**

5 NEW PATIENT FORM Patient Name: Date: **Please print, complete and return upon first office visit or complete during first office visit.** Use BLUE to indicate areas of numbness Use RED to indicate areas of pain

6 Pain Management Physicians Missed Appointment Policy Due to the high rate of cancellations and missed appointments without notifications, Pain Management Physicians has initiated a new policy. This policy is also to include appointments scheduled in the operation room for Pain Management Physicians and EAMC. You must notify our clinic 48 hours prior to your appointment for cancellations. TWO CUMULATIVE MISSED APPOINTMENTS without notification will result in dismissal from our clinic. Chronic cancellations will also be taken into considerations on a case by case situation and also can result in a dismissal from our clinic. Note: It is our policy that you must be seen in clinic and be re-evaluated before refilling any opiate or narcotics prescriptions for pain. It is important that you attend all scheduled appointments. If you have a missed appointment you must be seen in clinic before receiving your refills for medication. Refills will not be called into pharmacies. I have read the above policy and I fully understand its contents. Patient Name Patient Signature Date Witness **Official signature(s) will be collected during first office visit.**

7 Patient s Name DOB PAST MEDICAL HISTORY PLEASE CHECK ALL THAT APPLY Unremarkable Depression Asthma Diabetes Type 1 Atrial Fibrillation Diabetes Type 2 Anemia * Diverticulitis * Anxiety DVT * Autoimmune Disorder * GI Bleed * Bilary Cirrhosis GERD Blood Transfusions * Hemochromatosis * Brain Tumor Hyperlipidemia Cerebrovascular Disease Hypertension Cirrhosis Hypothyroidism CVA / Stroke Hyperthyroidism COPD Hepatitis A * Colon Cancer Hepatitis B Coronary Artery Disease Hepatitis C Crohn s Disease Infertility CRF Kidney Disease * Kidney Stone(s) * Liver Disease * MI Neurologic Disorder * Osteoarthritis Osteoporosis PVD PUD Rheumatoid Arthritis Seizure Disorder Thyroid Disorder * Tuberculosis Valvular Heart Disease UTI Recurrent * Varicose Veins/Phlebitis * Other PAST SURGICAL HISTORY PLEASE CHECK ALL THAT APPLY Unremarkable Craniotomy Abd Surg - Type Gastric Bypass Amputation Hemorrhoidectomy AV Fistula Creation Hip Replacement R L B AV Graft Interventional Pain Proc. Aortic Valve Replacement Knee Arthroscopy R L B Appendectomy Knee Replacement R L B B A-F Bypass Kyphoplasty Back Surgery L A-F Bypass Bronchoscopy Mitral Valve Replacement CABG Nephrectomy - Native Carotid Endarterectomy Nephrectomy - Transplant Carpal Tunnel Pacemaker Cataract Extraction R L B Parathyroidectomy Cholecystectomy Pneumonectomy Colon Resection Prostatectomy PTCA R A-F Bypass Rotator Cuff Repair R L B TURP + Tonsillectomy Tunneled Dialysis Catheter UPPP Urinary Incontinence Surgery Vertebroplasty Anesthesia Problems Anesthesia Problems Surgical Complications Surgical Complications Post OP Delirium Other

8 Patient s Name DOB FAMILY HISTORY PLEASE CHECK ALL THAT APPLY Please indicate which family member: i.e., mother, father, brother, etc. Unknown Alcoholism Anemia Arthritis Anesthetic Complication Anxiety Asthma Birth Defects Bleeding Disease Breast Cancer R L B Colon Cancer Depression Diabetes Heart Disease Hypertension High Cholesterol Kidney Disease Lung/Respiratory Disorders Migraines Osteoporosis Seizures Severe Allergies Stroke Thyroid Problems Other SOCIAL HISTORY PLEASE CHECK ALL THAT APPLY Current Every Day Smoker Current Some Day Smoker Former Smoker Never Smoked Smoker Current Status Unknown Unknown if Ever Smoked Counseled to Quit? Passive Smoker Alcohol Use Recreational Drug Use HIVA/High Risk Currently Employed What kind of work: I live in a Home/House I live in an Apartment Who lives with you? Are there any stairs in your Home/Apt?

9 Patient s Name DOB RISK FACTORS PLEASE CHECK ALL THAT APPLY Year Started TOBACCO USE: Cigarettes Amt: Pack/Day Cigars Amt: Pack/Day Smokeless Tobacco Amt: Pack/Day Counseled to Quit ALCOHOL USE: Type of Drink Felt the Need to Cut Down Been Annoyed by Complaints Felt Guilty RE: Drinking Needed Eye Opener in A.M. Counseled to Quit Drinks Per Day CAFFEINE USE: Caffeine Drinks Per Day EXERCISE: Type of Exercise # of Times per Week OTHER: Seatbelt Use (%) Sun Exposure (%) Date of last Colonoscopy Date of last Mammogram Date of last Pap Smear

10 Patient s Name DOB Pain Management Physicians Missed Appointment Policy PLEASE List ALL Prescriptions and Over the Counter Medications If you use an attachment, it must have Medication Name, Dosage, and Instructions MEDICATION DOSAGE INSTRUCTIONS Example: Ambien 5 mg Tabs 1 at bedtime

11 Patient s Name DOB Oswestry Disability Questionaire This questionnaire has been designed to give us information as to how your pain is affecting your ability to manage in everyday life. Please answer by checking one box in each section for the statement which best applies to you. We realize you may consider that two or more statements in any one section apply, but please shade only the box that indicates the statement which most clearly describes your problem. SECTION 1: PAIN INTENSITY I 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 6: STANDING I can stand as long as I want without extra pain I can stand as long as I 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 min. Pain prevents me from standing for more than 10 min. Pain prevents me from standing at all SECTION 2: PERSONAL CARE (eg. washing, dressing) I can look after myself normally without causing extra pain I can look after myself normally but it causes extra pain It is painful to look after myself and I am slow and careful I 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 7: SLEEPING My sleep is never disturbed by pain My sleep is occasionally disturbed by pain Because of pain I have less than 6 hours sleep Because of pain I have less than 4 hours sleep Because of pain I have less than 2 hours sleep Pain prevents me from sleeping at all SECTION 3: LIFTING I 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 I can manage if they are conveniently placed (eg. on a table) Pain prevents me lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned I can only lift very light weights I cannot lift or carry anything 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 severely restricted by pain My sex life is nearly absent because of pain Pain prevents any sex life at all 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 1 / 2 mile Pain prevents me from walking more than 100 yards I can only walk using a stick or crutches I am in bed most of the time 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. sports) Pain has restricted my social life and I do not go out as often Pain has restricted my social life to my home I have no social life because of pain SECTION 5: SITTING I can sit in any chair as long as I like I can only sit in my favorite chair as long as I like Pain prevents me from sitting more than 1 hour Pain prevents me from sitting more than 30 min. Pain prevents me from sitting more than 10 min. Pain prevents me from sitting at all SECTION 10: TRAVELING I can travel anywhere without pain I can travel anywhere but it gives me extra pain Pain is bad, but I manage journeys more than 2 hours Pain restricts me to journeys less than 1 hour Pain restricts me to short necessary journeys less than 30 min. Pain prevents me from travelling except to receive treatment