Trinity Pain Center New Patient History Form

Transcription

1 Trinity Pain Center New Patient History Form NAME: TODAY S DATE: DATE OF BIRTH: MALE FEMALE PRIMARY PHYSICIAN REFERRING PHYSICIAN WHERE IS YOUR PAIN? WHEN DID YOUR PAIN BEGIN? HOW DID YOUR PAIN BEGIN? Accident at work Accident at home Illness Auto Accident No known cause Other: ARE YOU INVOLVED IN LEGAL ACTION? WHAT BEST DESCRIBES YOUR PAIN? (Please check all that apply.) ALWAYS: SHARP DULL ACHING DEEP SHOOTING ELECTRICAL STABBING BURNING SOMETIMES: SHARP DULL ACHING DEEP SHOOTING ELECTRICAL STABBING BURNING Do you have numbness? Yes No If so, where? Arms Legs Hands Feet Other: Please circle the number that best describes the amount of pain you feel right now. No Pain Worst Pain What is the highest number you pain reaches? What pain level is a realistic goal for you? Please mark the painful areas on the diagram below

2 What makes your pain worse? Standing Walking Climbing stairs Sitting Bending forward Bending backwards Lifting Driving Light touch Coughing/Sneezing Cold Sexual activity Stressful situations Work What relieves your pain? Lying down Sitting Standing Walking Physical therapy Exercise Bath/Shower Heat Medications Ice Meditation Relaxation Have you ever been treated by another pain management center? Yes No Prior Pain Doctor: Last Seen: List prescription and over-the-counter medications, vitamins, and herbal supplements you are taking. Name of medication Prescribing doctor Dose/mg # of times per day Do you take any blood thinners? (Coumadin, Plavix, Aspirin) Yes No If yes, what? Medication, food or other allergies Adverse reaction Medical History Cardiovascular Chest pain Heart attack Heart disease Heart arrhythmias High Blood Pressure Embolism Low Blood Pressure Respiratory Asthma Emphysema Chronic Bronchitis Pneumonia Gastrointestinal Ulcers Polyps Colitis Hiatal hernia Irritable bowel syndrome Acid Reflux/GERD Crohn s Liver Disease Hypothyroid Hyperthyroid Diabetes Pancreatitis Endocrine Hematologic Neurological Psychological Anemia Bleeding disorders Easy Bruising Hepatitis A, B, C Blood thinners Blood clots Seizures Stroke Headaches Epilepsy Neuropathy Muscular Dystrophy Depression Anxiety Panic Disorder Insomnia Psychosis Genitourinary Chronic UTI s Sexual Dysfunction Prostate Disease Urinary incontinence Osteoarthritis Osteoporosis Spinal stenosis Sciatica Musculoskeletal Cancer Site: Diagnosis Date: Chemotherapy Radiation Immunological Lupus Sjogren s Raynaud s Immune deficiency HIV Rheumatoid Arthritis Medical Equipmen Cane Walker Wheel Chair Hospital Bed Oxygen at Lpm Eyes Glaucoma Cataracts Need for glasses

3 Past Studies Performed Date Imaging Center X-ray MRI Date Surgical History Doctor Past Treatments Dates Performed Please select the treatments and indicate the result. Epidural steroid injections Better Worse No Change Not tried Facet joint injections Better Worse No Change Not tried Trigger point injections Better Worse No Change Not tried Nerve blocks Better Worse No Change Not tried Nerve Ablation Better Worse No Change Not tried Physical therapy/exercise Better Worse No Change Not tried Manipulation/Chiropractic Better Worse No Change Not tried Spinal cord stimulation Better Worse No Change Not tried Family Medical History Age health problems cause of death Father Mother Siblings Psychosocial History Highest level of education completed: grade school high school college graduate school post-graduate Are you going to school now? Yes No Working Homemaker Not working due to pain Retired due to pain Not working due to other reasons Retired, not due to pain On leave from work Out of work because of a work injury Receiving Social Security Disability Other Receiving worker s compensation What is/was your occupation? Have you ever been in the military? Yes No Job description, duties, tasks: Has your job changed because of you painful conditions? Yes No If yes, how? Are you able to care for yourself? Yes No If not, who helps you? Have you fallen lately? Yes No When? How many people live in your household? Spouse Children Friends Siblings What exercise or recreational activities do you enjoy? Walking Home exercise Dancing Bicycling Swimming Yoga Hiking Golf Tennis Other:

4 How often do you exercise? Daily Weekly Monthly Never What activities have you stopped due to pain? Recent stressful experiences? Health problems Financial Divorce Loss of a loved one Work Relocation Have you ever had thought of suicide or harming yourself? Yes No Did you seek help? Yes No Have you ever been under the care of a mental health professional? Yes No If so, who? Have you ever been in treatment for alcohol or substance abuse? Yes No If so, when? Does anyone in your household have a substance abuse problem? Yes No If so, who? Have you used any of the following? Date last used Current use How often and for how long? Tobacco packs per day X Years Alcohol beverages per day/week/month Caffeine-containing Beverages beverages per day/week/month Marijuana/other: Constitutional Other Symptoms Fatigue Weight loss weight gain Fever Chills Night Sweats Syncope/Fainting Endocrine Loss of Appetite excessive thirst Excessive urination heat/cold intolerance Hematologic HENT Eyes Respiratory Easy Bruising Easy Bleeding Sinus problems Sore throat Hoarseness Dry mouth Hearing loss Ringing in ears Vision change Blurry vision Double vision Eye pain Cough Shortness of breath Wheezing Spitting up Blood Cardiovascular Chest pain Leg Swelling Palpitations Gastrointestinal Constipation Bowel problems Nausea Vomiting Diarrhea Abdominal pain Genitourinary Painful urination Sexual Dysfunction Urinary Frequency Urinary incontinence Neurological Headaches Memory problems Numbness/Tingling Restless legs Vertigo/Dizziness Balance problems Psychological Depression Anxiety Insomnia Nervousness Libido decreased Musculoskeletal Joint pain Joint swelling/stiffness Muscle weakness Immunological Frequent Colds Persistent infections Medical Equipment Cane Walker Wheel Chair Hospital Bed Oxygen at Lpm Skin Rash Change in color Tenderness/pain Infection/bite/wound What do you expect from our pain program? A diagnosis A cure Help coping A reduction in pain No expectations Don t know what to expect To report a complaint regarding the services you receive, please call the Agency for Health Care Administration toll-free ( ). To report neglect, or exploitation, please call the Florida Department of Children and Families toll-free ( ). These contact numbers are posted in lobby for your future reference. Patient Signature Date Reviewed by Practitioner Date

5 Trinity Pain Center new patient information First Name: Middle Initial: Last Name: Street Address: City: State: Zip: Home Phone: Mobile Phone: Address: Birth Date(mm/dd/yyyy): Current Age: Height: Weight: Gender: Social Security Number: Spouse s Name: Name of employer or school: Work/School Telephone #: Employer/School Address: Primary Care Physician: Phone #: Date of last doctor visit: Emergency Contact Name Phone Number(s): Relationship Have you been in pain management before? For what problem? Referring Physician: Phone Number: insurance information Primary Insurance: ID# Group# Insurance Company Address: Insurance Company Phone: Note: Insurance company s address and phone number are typically found on the back of your insurance card. Trinity Pain Center 8146 Cerebellum Way Suite 102 Trinity FL (727)

6 Trinity Pain Center new patient information = Subscriber: DOB: SS# Subscriber s Employer: Employer address: Employer Phone: *Subscriber is the name of the family member from which the policy originates. secondary insurance information Secondary Insurance: ID# Group# Insurance Company Address: Insurance Company Phone: Subscriber: DOB: SS# Subscriber s Employer: Employer address: Employer Phone: Do you have a prescription plan? YES NO authorization I hereby authorize payment directly to the Physician of the Surgical and/or Medical Benefits, if any, otherwise payable to me for his services as described, realizing I am responsible to pay non-covered services. I hereby authorize Trinity Pain Center, LLC to release any information acquired in the course of my treatment necessary to process insurance claims. I authorize any holder of medical or other information about me to release this information to my insurance company, its intermediaries or carriers, to my attorney or to another physician s office. I also permit a copy of this authorization to be used in place of the original. This agreement will remain in effect until revoked by me in writing. Signature: Date: Trinity Pain Center 8146 Cerebellum Way Suite 102 Trinity FL (727)