Southern Interventional Pain Center New Patient Evaluation Form
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- Cory Peters
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1 Southern Interventional Pain Center New Patient Evaluation Form Page 1 of 5 Name: D.O.B. Today s Date: Chief Complaint and History of Present Illness Please list your DAILY SEVERE AREAS OF PAIN only: LOW BACK PAIN: Start date: Due to: gradual sudden constant comes/goes better worse same NECK PAIN: Start date: Due to: gradual sudden constant comes/goes better worse same OTHER: Start date: Due to: gradual sudden constant comes/goes better worse same Mark your MOST SEVERE areas of pain? Mark and draw below (draw X on most severe areas of pain and use arrows for radiating pain) Describe your pain: ache burn cramp dull sharp stabbing tearing throb numbness pins/needles Rate your pain level NOW: WORST pain level in past week: LOWEST pain level in past week: Associated symptoms: numbness loss of bladder stiffness weakness control swelling fevers loss of bowel redness/warmth chills control sleep problems weight loss can t empty bladder Other imbalance Please list recent imaging: X-rays: neck low back other Dates: MRI: neck low back head other Dates: CT scans: neck low back head other Dates: EMG/Nerve Study: yes Dates: Other: Dates:
2 Page 2 of 5 Past treatments: Rest Ice Heat Exercise program Physical therapy TENS Bracing Chiropractic Joint injections Trigger point injections Facet joint injections RFA/Rhizotomy Epidurals Nerve blocks: Spinal cord stimulator Pain pump Other: Past medications: (indicate the PAIN medications you have tried in the PAST and NOT currently taking): Anti-inflammatories: Muscle Relaxers: Opioids: Nerve Medicines: ibuprofen (Motrin/Advil) Baclofen tramadol (Ultram/Ultracet) gabapentin/neurontin naproxen (Aleve) Flexeril hydrocodone (Lortab/Vicodin Lyrica meloxicam (Mobic) Robaxin /Lorcet/Norco) Cymbalta diclofenac (Voltaren/ Soma oxycodone (OxyContin/Endocet amitriptyline (Elavil) Pennsaid/Flector) Skelaxin /Percocet/Tylox) nortriptyline (Pamelor) Indomethacin (Indocin) Zanaflex Dilaudid Savella piroxicam Valium morphine (Kadian, MS Contin) Topamax Relafen Norflex Opana Tegretol Toradol Methadone Trazodone Celebrex fentanyl (Duragesic/Actiq) Other: sulindac Nucynta Lidoderm etodolac (Lodine) Exalgo capsaicin aspirin (BC/Goody s/bayer/excedrin) Butrans menthol Suboxone (buprenorphine) Tylenol/codeine (Tylenol #3/#4) Past evaluations: Have you seen a PAIN MANAGEMENT SPCECIALIST in the past? Yes No, if yes then who? List the pain medications they were recently prescribing you IF you are not currently taking them: Medication Dose Number of pills/day Were you discharged from the practice? Yes No. If yes, why? List ANY OTHER specialists you have seen about your pain:
3 Page 3 of 5 Medications Please list all medications that you are currently taking, INCLUDE OVER THE COUNTER Medication Name Dosage Frequency Who Prescribed Medication Allergies List Allergies Reaction you had Past Medical History ADD/ADHD AIDS/HIV Abuse-sexual or domestic Acid reflux Anemia Anxiety Asthma Arrhythmia Atrial fibrillation Bipolar disorder Blood clots Brain injury Cancer (type:, remission?: yes no) COPD (home oxygen?: yes no) Depression Diabetes Fibromyalgia Fractures: Gastrointestinal disease Gout Heart disease Hypertension Kidney stones Migraines Neuropathy Osteoarthritis Osteopenia Osteoporosis Rheumatoid arthritis Sleep apnea (CPAP?: yes no) Seizures Stroke Thyroid disease Ulcers Other: Lupus Past Surgical History Provide a complete list of ALL surgeries. (Use back of page if necessary) Spine surgery (cervical/thoracic or lumbar?, number of times, levels involved and dates): ALL OTHER:
4 Page 4 of 5 Family History Please list any major illness in your family: Autoimmune disease Diabetes Mental disorder Back/spine problems Fibromyalgia Neuropathy Bleeding disorder Heart disease Substance abuse Stroke Hypertension Lupus Chronic pain Depression Cancer, type?: Tobacco dependence Other: Social History Tobacco Use: Never Quit Current: daily some days of week for # of years Marital Status (circle one): Single Married Separated Divorced Widowed Domestic partner Occupation: employed, type of work: unemployed retired student disabled Education: high school grad, if no highest grade: trade school college graduate/professional school Alcohol Use: Never # of Beer(s)/week # of Liquor drinks/week # of Wines/week Recovering Alcoholic: # of years sober Illicit Drug Usage: Never Past History Current. Please list drugs used Drug/Alcohol Abuse Treatment in Past: Yes No. If yes, In-Patient Out-Patient Both Exercise (circle one): Not Exercising Occasional Moderate Heavy Difficulty Walking/Climbing: Yes No Able to Care for Self: Yes No, Caregiver: Yes No Constitutional Lethargy/sedation Fevers Weight loss ENT Hearing loss Snoring Review of Systems Symptoms you are CURRENTLY having only: Fainting CV Palpitations Resp Short of breath Sleep apnea GI Nausea/vomiting Constipation GU loss of urine control Urinary retention Seizures Neuro Dizziness Psych Depression Anxiety Insomnia Heme/Lymph Swollen glands Easy bruising Skin/Allergy rashes itching allergic reaction By signing below I certify that the above information is true to the best of my knowledge and I consent for the provider to evaluate, and treat me for the condition or conditions present above. Signature of Patient, Guardian or Patient Representative Date
5 Page 5 of 5 Southern Interventional Pain Center Patient s Name: Previous Name: CONSENT TO RELEASE HEALTHCARE INFORMATION Date of Birth: Social Security #: Max Shokat, DO Fax I request and consent that release healthcare information of the patient named above to: Southern Interventional Pain Center to Address: 615 South Hansell Street City: Thomasville State: GA Zip Code: This request and authorization applies to: Healthcare information relating to the following treatment, condition, or dates: All healthcare information Other: Definition: Sexually Transmitted Disease (STD) as defined by law, RCW et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea. Yes No I consent the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone. Yes No I consent the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. Patient Signature: Date Signed: THIS CONSENT EXPIRES 180 DAYS AFTER IT IS SIGNED.
Patient Name (First, Middle, Last) Height Weight. Ethnicity Race Language. Address. City State Zip. Home Phone Cell Phone. Work Phone Other Phone
Patient Name (First, Middle, Last) Height Weight Date of Birth Social Security # Gender Male Female Ethnicity Race Language Address City State Zip Home Phone Cell Phone Work Phone Other Phone Email Occupation
PAIN INFORMATION SHEET
PAIN INFORMATION SHEET PLEASE MARK THE AREAS ON YOUR BODY WHERE YOU FEEL THE SENSATIONS DESCRIBED BELOW. PLEASE USE THE APPROPRIATE SYMBOL & INCLUDE ALL AREAS. **** ==== OOOO XXXX //// ACHE **** NUMBNESS
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
Initial Pain Questionnaire
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DOB Age Sex Weight Height Right Handed Left handed
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*542686* How severe is the problem? mild moderate severe Is it getting better or worse? Better Worse Same over the last hours days weeks months
*542686* Referring Doctor Name: Specialty: City: State: Primary Doctor Name: Specialty: City: State: Instructions: On the body drawing below, please show where you feel pain at this time. Please mark only
CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
JOSE G. VELIZ MD, INC. Diplomate of the American Board of Interventional Pain Management Diplomate of the American Board of Anesthesiology Diplomate of the American Board of Pain Medicine Fellow of Interventional
Using the symbols below, please draw in the location of your symptoms on the diagrams. X = Pain 0 = Numbness / = Aching * = Pins & Needles
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New Patient Information and History Form
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