Coming South on US 281: Go to shopping center. Coming North on
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1 Consultants in Pain Medicine, P..A. Stephanie S. Jones, M.D. Phone (210) Fax (210) E Basse Suite 117; Located in the Village on the Green shopping center at the corner of East Basse and Treeline Park. Coming South on US 281: Exit at Sunset (after Airport Exit) and follow road to stop light on Sunset. Take a left on Sunset and go under the freeway. Go to stop light and take a right onto Treeline Park. Continue for.7 miles. Turn Right into the Village on the Green shopping center. Coming North on US 281: Exit at E. Basse and turn right on to Basse. Go to Treeline Park and take a left. Turn Left into the Village on the Green shopping center. Coming west on Loop 410 (heading west): Exit on Broadway and take a left on Broadway (under 410). Come to East Basse and take a right. Turn Right onto Treeline Park. Turn Left into the Village on the Green shopping center. Coming east on Loop 410 (heading east) : Exit at (21B Airport Blvd exit). Turn right on US 281 access road. Come to stop light at Sunset.. Take a left on Sunset andd go under the freeway. Go to stop light and take a right onto Treeline Park. Continue for.7 miles. Turn Right into the Village on the Green shopping center.
2 Consultants in Pain Medicine, P.A. 555 E Basse Suite 117 Phone (210) Fax (210) DATE: Dear Mr./Mrs./Ms., You have been referred to Stephanie Jones, M.D., with Consultants in Pain Medicine by your physician. Please complete the enclosed information regarding your pain on the patient intake form provided for you. You must bring the questionnaire completed to the office on, at a.m./p.m. at our 555 E Basse Suite 117 location. (arrival time) (see map attached) ATTACHED WITH THE PACKET YOU MUST HAND CARRY ANY MRIs, X-RAY OR CT FILMS. IF THE FORMS ARE NOT COMPLETELY FILLED OUT AND YOU DO NOT HAVE YOUR FILMS YOUR APPOINTMENT MAY BE RESCHEDULED. Please be aware that you are liable for any applicable co-pays at office and facility visits. Please follow up with your insurance company to be prepared for the cost that may possibly be incurred. Please bring your insurance card to your appointment. If you do not understand the questions and require assistance arrive 30/45 minutes prior to your office appointment and please call our office. * If you are scheduled for an injection at the surgery center please arrive at least 1 hour prior to your procedure. You must bring a driver. You should not eat or drink for 6-8 hours prior to your procedure except for essential medications which can be taken with a sip of water only. *Please notify our office if you are taking any Blood Thinners so we can arrange your lab work to be done prior to your procedure. Also, if you are on a blood thinner for cardiac reasons, especially an artificial heart valve, you must discuss stopping it with your primary care physician or cardiologist first. If you are placed on Lovenox, it must be stopped 12 hrs. prior to your procedure. We appreciate your cooperation and if you have any questions or require further assistance, please feel free to contact our office. Thank you, Ruth the Scheduler
3 Consultants in Pain Medicine, P.A. 555 E Basse Suite 117 Phone (210) Fax (210) While under the care of Stephanie Jones M.D., she may recommend you undergo certain procedures to maintain your pain. In that time certain medications cannot be taken. Please look over the medications below and CIRCLE the medication(s) that you are currently taking and return to our office signed. This will help us remind you on how to prepare for your procedure. Please remember to continue to take all blood pressure, diabetes medication, and any other medications that you take on a regular basis that do not contain blood thinning agents. If there is a medication you have a question about, please do not hesitate to call. **DO NOT DISCONTINUE ANY MEDICATION IF YOU ARE SCHEDULED FOR A REGULAR OFFICE VISIT.** ***PLEASE CHECK WITH YOUR PRIMARY CARE PHYSICIAN PRIOR TO DISCONTINUING ANY PRESCRIBED ANTICOAGULANTS.*** The following medications must be STOPPED SEVEN DAYS PRIOR to your procedure, otherwise you will be rescheduled. Aggrenox/Dipyridamole/ Persantine Garlic Supplemennt Tirofiban Ginger More than 1 Aspirin /day Dalteparin/Fragmin Vitamin E Ginseng Normiflo/Aredparin Halfprin (Aspirin) Empirin (Aspirin) Ginko BE SURE TO NOTIFY YOUR PRIMARY CARE PHYSICIAN PRIOR TO STOPPING PRESCRIPTION MEDICATIONS. The following must be STOPPED AT LEAST FOUR DAYS PRIOR to your procedure, otherwise you will be rescheduled. Coumadin/Warfarin Plavix/Clopidogrel Ticlid/Ticlopidine The following must be STOPPED AT LEAST 24 HOURS PRIOR to your procedure, otherwise you will be rescheduled. Lovenox/Enoxaparin The following medication may be taken until the day of your procedure: No more than 1 aspirin per day, Tylenol, non-steroidal anti inflammatory drugs (i.e., motrin, advil, aleve, naprosyn, mobic )
4 Consultants in Pain Medicine, P.A. 555 E Basse Suite 117 Phone (210) Fax (210) I hereby authorize Consultants in Pain Medicine, Inc., to take my photograph for inclusion in my medical chart retained by the clinic. I understand this photograph is solely for the purpose of identification and familiarization by the office staff and the clinic physician(s). Patient Signature Please fill out and sign the following release form so we can obtain copies of any medical records that may be needed in order to assess your condition more thoroughly. Date: I, hereby authorize the release of my medical records to Consultants in Pain Medicine. Patient Signature Date Witness: Date
5 Information Form DATE: Name: Date of Birth: Age: Employer: Occupation: Do you work now? Yes No Part Time What does your work involve? Name of Doctor who referred you? List of other Doctors you have seen for this pain problem: Names of other Doctors you see for other medical reasons: How long have you had your pain? Give details of injury or circumstances causing your pain: Were you injured on the job? Yes No Is there an attorney involved? Yes No How and when were you treated for this problem? Have you had surgery for this problem? Yes No If yes, give: Date Hospital Name of surgeon Tests performed: X-Rays MRI CT Scan EMG Bone Scan Discogram Other Tests Where & When: What is your pain status now? Worse Better Same Has it changed? How? What other treatments have you received? (i.e., bedrest, physical, therapy, hypnosis, chiropractic manipulation, acupuncture, injections) Please list details: Treatment: Where:
6 When: MEDICATIONS Please list medications to which you are ALLERGIC, and the type of reaction to each (i.e. rash, upset stomach, etc..): Please list medications you have previously taken for pain: MEDICATION HELPFUL? REASON FOR STOPPING USE Please list medications you are CURRENTLY TAKING FOR PAIN: MEDICATION DOSAGE TIMES/DAY HELPFUL? DOCTOR Please list other medications you are CURRENTLY TAKING (include vitamins, etc.): MEDICATION HELPFUL? DOCTOR Please circle on a scale of 0 to 10 (0 is no pain 10 is the worst imaginable) AT ITS BEST MOST OF THE TIME
7 AT ITS WORST For the following descriptions, place a SINGLE number for each word that describes you pain: NONE = 0 MILD = 1 MODERATE = 2 SEVERE = 3 THROBBING HEAVY SHOOTING TENDER STABBING SPLITTING SHARP TIRING/EXHAUSTING CRAMPING SICKENING GNAWING FEARFUL HOT/BURNING PUNISHING/CRUEL Married? Yes No How many children do you have? Level of Education? What type of work do you do? Have you lost or gained weight in the last six months? Yes No How many pounds? Lost lbs. Gained lbs. Do you: Drink alcoholic beverages? Yes (Amt) No Smoke? Yes (Amt) No Have you ever been treated for addiction to alcohol or any other substance? Yes No Do you currently take any illegal drugs or have you taken any narcotics in a non-prescribed manner? Yes No FAMILY HISTORY (Circle all that apply TO YOUR BLOOD RELATIVES) Asthma Genetic Disorders Kidney Problems Arthritis Headaches Lung Problems Cancer Heart Problems Seizures Diabetes High Blood Pressure Tuberculosis Other: Please circle any of the following that APPLY TO YOU Anxiety Constipation GI Bleed Heart Problems Kidney Problems Tuberculosis Arthritis Depression Glaucoma HIV Lung Problems Asthma Diabetes Hepatitis High Blood Pressure Stomach Ulcer Cancer Genetic Disorder Headaches Impotence Seizures Other: Please list previous surgeries: DATE PROCEDURE SURGEON HOSPITAL
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