Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C
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1 Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite Jesse Jewell Parkway 1404 River Place Gainesville, GA Braselton, GA Phone Phone Fax Fax Dear Valued Patient, We are so grateful you have entrusted us for your healthcare needs. We look forward to serving you. Based upon the information obtained from your referring physician, as well as Dr. Slack s assessment of you, a treatment plan will be formulated. Example treatment plans consist of site specific injections targeting the underlying cause of pain. Please note: Opioid therapy (common Opioids include: Lortab, Percocet, Fentanyl, etc.) may or MAY NOT be used. Please do not expect to receive a prescription for an opioid medication at your visit. If you would like to discuss the above treatment approach prior to your visit, please contact our office. Please arrive 20 minutes prior to your scheduled appointment. Please bring your Photo ID and Insurance Card(s) along with any imaging discs. Please complete the following paperwork prior to your appointment with Interventional Pain Medicine and bring it with you to your appointment. If you wish to change your appointment date or time, please call our office at Best Regards, The Scheduling Department neurosciences.scheduling@nghs.com
2 Northeast Georgia Physicians Group- Interventional Pain Medicine DATE: NAME: AGE: Weight: Height: BP: / Pulse: Resp: O2: Temp: What problem are we seeing you for? Have you had CT, MRI, X-Rays or EMG Study done? Yes No If so, where and when: PAST MEDICAL HISTORY: Have you ever been diagnosed with any of these conditions? Migraine Headaches Low Blood Pressure Stomach Ulcers Prostate Enlargement Implanted Devices High Cholesterol Diabetes Epilepsy Stroke Thyroid Disease Low Blood Sugar Arthritis Carotid Artery Disease Asthma Liver Disease Fibromyalgia Coronary Artery Disease Emphysema Hepatitis Psychiatric Disorder Heart Attack COPD Kidney Stones Anxiety Abnormal Heart Rhythm Congestive Heart Failure Kidney Disease Claustrophobia High Blood Pressure Tuberculosis Anemia Have you ever had cancer? Yes No Where? PAST SURGICAL HISTORY: Have you ever had any of the following surgeries? Back Surgery Cardiac Stent When: Neck Surgery Joint Replacement Which Joint(s)? Carotid Surgery Other Joint Related Surgeries Brain Surgery Carpal Tunnel Repair Pacemaker Spinal Cord Stimulator Trial SOCIAL HISTORY: Alcohol Use: Yes No How Often? History of Substance Abuse: Yes No Tobacco Products: Yes No Packs per day? Are you Pending Litigation? Yes No Are you currently working? Yes No Occupation? Married Divorced Widowed Single Disability? Yes No Pending Seeking FAMILY HISTORY: Do any of your blood relatives have or have they ever had any of these conditions? Heart Disease Kidney Disease Psychiatric History Hypertension Neurological Illness / Disorder Drug Abuse Stroke Seizure Disorder Parkinson s Disease Back Surgery Diabetes Arthritis Migraines Brain Aneurysm Trembling Family Member(s) currently on narcotics? Yes No Family History of Cancer? Yes No If Yes, What type(s)? REVIEW OF SYSTEMS (Check Current or Present Symptoms): GENERAL: Weight Loss Weight Gain Fatigue Weakness Fever Chills
3 SKIN: Rashes Lesions Lumps Slow Healing Wounds EYES: Pain Double Vision Blurry Vision Loss of Vision EARS, NOSE & THROAT: Hearing Loss Ringing in Ears Vertigo Nose Bleed Sore Throat RESPIRATORY: Cough Wheezing Shortness of Breath Painful Breathing CARDIOVASCULAR: Chest Pain or Discomfort Swelling Shortness of Breath with Activity Tightness GASTROINTESTINAL: Nausea Vomiting Constipation Diarrhea VASCULAR: Leg Cramping Leg Swelling Calf Pain when Walking MUSCULOSKELETAL: Muscle or Joint Pain Muscle Weakness Stiffness NEUROLOGIC: Weakness Numbness Tingling Tremor Memory Loss Difficulty Walking Headache Off-Balance Dizziness PSYCHIATRIC Loss of Concentration Anxiety Irritability Depression HEMATOLOGIC: URINARY: Ease of Bleeding Ease of Bruising Frequency Painful Urination All other systems reviewed and negative Allergies? Yes No If yes, please list allergies and reactions: Please note: As NGPG Interventional Pain Medicine utilizes alternative treatment options for pain, opioid medications (example: Lortab, Percocet, Fentanyl, etc.) will not be prescribed unless deemed clinically appropriate by your provider. Your signature below represents your acknowledgement of this policy. Patient Signature Date:
4 Northeast Georgia Physicians Group- Interventional Pain Medicine Pain Survey *Please Thoroughly Complete Both Sides of This Survey* Name: Date: Location: In what part of your body is your pain the worst? Radiation/Referral Pattern: Does your pain travel to other locations? (Please be as specific as possible.) Quality: How would you describe your pain (aching, burning, etc.)? Severity: Rate your pain on a scale of 1-10: Duration: For how long have you experienced your current pain? Is the pain constant? Timing: At what time of day (or night) is the pain at its worst? Aggravating Factors: What activities worsen the pain? Alleviating Factors: What makes the pain better? Functionality: Are you exercising, walking, stretching, etc? Work: Are you working full-time? Part-time? Sleep: How many hours of sleep do you get per night? Would you consider this quality sleep? Mood: How is your mood (irritable, sad, happy most of the time, etc.)?
5 Pain Diagram Name: Date: Please mark the area of injury or discomfort on the chart below, using the appropriate symbols: Numbness Pins & Needles Burning Aching Stabbing O O O O O ^^^^^ xxxxx O O O O O ^^^^^ xxxxx Please make a slash through the line below to indicate your current pain level. No Pain Worst Possible Pain Patient Signature: Date:
6 *MEDICATION LIST* NAME: DOB: PHARMACY: PHONE: PLEASE PROVIDE US WITH COMPLETE LIST OF MEDICATIONS BELOW, INCLUDING DOSE AND HOW MANY TIMES PER DAY YOU TAKE EACH MEDICATION. MEDICATION DOSE TIMES PER DAY
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
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:
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left HISTORY OF PRESENT ILLNESS
CAPS PAINCARE Page 1 of 5 Today s : / / SSN (last 4 digits): xxx-xx - Patient Name: DOB: Age: Sex: Male Female Height: Weight: Dominant Hand: Right Left Type of Accident/Injury: Auto Work Personal Injury
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
Past Surgical History
Name: DOB: Check All That Apply Past Medical History o Anemia o Aneurysm o Asthma o Bipolar o Bleeding Disorder o Blood Clot o Brain Tumor o Bronchitis o Cancer o Crohn s Disease/Ulcerative Colitis o Depression
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
City State Zip. Cell Phone. Other Phone. Gender Male Female Status Single Married Divorced Widowed. Height Weight EXERCISE Yes No Times per Week
Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
NEW PATIENT VISIT QUESTIONNAIRE
HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred
Address: City: Postal Code: Emergency Contact: Phone# Relationship: Who may we thank for referring you to this office?
CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
Please mark the severity of your pain on the following line: On your worst days with a W On your average days with an A On your best days with a B
Today s Date: NEUROSURGERY Name: (Last) (First) (MI) Age: Birth Date: Female Male Dominant hand: Right Left Pharmacy- Name: Phone: Location: What are you being seen for today? Location of pain (indicate
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
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DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form Today's date: Your name: Date of birth: Email address: CHIEF COMPLAINT What is the main reason that you are seeking medical attention? Please
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I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Patient Name: First MI Last Preferred Name. DOB: Sex: MALE FEMALE SSN: Address: City: State: Zip Code:
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Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
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Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Spine New Patient Questionnaire Rev
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Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
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Samuel A. Joseph, Jr., M.D. In order to be seen by one of our physicians, you must bring the following to your visit:
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ANY FAMILY HISTORY OF ANEURYSM OR DVT?
NAME: D/O/B: DATE: MR# WHAT PROBLEM(S) BRINGS YOU HERE TODAY? WHO SENT YOU TO US? DOCTOR/OTHER WHICH DOCTOR? WHAT SURGERY HAVE YOU HAD AND WHEN? (LIST) 1. 2. 3. 4. 5. 6. 7. HOW MUCH ALCOHOL DO YOU DRINK
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927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
*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
Name: [Type text] Date of Birth: ENDOCRINOLOGY HEALTH HISTORY. What is the reason for your visit?
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ENDOCRINOLOGY HEALTH HISTORY What is the reason for your visit? MEDICATIONS List current prescription and over-the-counter medications. Also list current vitamin, herbal, and nutritional supplements: MEDICATION/SUPPLEMENT
NEW SPINE PATIENT. Date Seen: Blood Pressure: Pulse: Weight: Height: O 2. How long (days, weeks, or years) has this complaint/problem been going on?
ROOM #: NEW SPINE PATIENT Date Seen: Blood Pressure: Pulse: Weight: Height: O 2 Sats: For office use only above this line. Patient Name: Referring Physician: Date of Birth: Age: Insurance Carrier: Present
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
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Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
N N X X === === === === N N X X === u u s s. Physician Signature: OrthoNeuro
Physician Signature: OrthoNeuro Date: Name: Date: Age: SS#: Sex: DOB: Referring Physician: Referring Physician Address: Mark the areas on the corresponding figures where you feel the described sensations.
Morris Medical Center, P.A.
Today s date: Name : Age Date of Birth Height Weight Right hand dominant Left hand dominant Sex: Male Female Chief Complaints; Current Pain Level (0 ~ 10) 0 1 2 3 4 5 6 7 8 9 10 Average Pain Level (0 ~
PATIENT HISTORY FORM
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COMPREHENSIVE PAIN MANAGEMENT INTAKE FORM. Home Phone: Other Contact: Other Contact: Address: City: State: Zip: Address: City: State: Zip:
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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
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Hospital he hospital is located near the interchange of highway 217 and (US 26).
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