CHRONIC PAIN EVALUATION. Please help us understand your pain by completing this drawing:
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- Shana Stevenson
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1 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 Pain Practice Name: : CHRONIC PAIN EVALUATION Please help us understand your pain by completing this drawing: A) Use the pictures below to show the origin of your pain. (mark with a solid dot) B) Does the pain travel or radiate anywhere? (mark with a broken line) Please list your areas of pain from most painful to least painful: 1. _ 5. _ 2. _ 6. _ 3. _ 7. _ 4. _ 8. _
2 Please help us understand your pain by answering the following questions: 1) When did your pain start? 2) Is your pain aggravated by work? [ ] yes [ ] no If so, how? 3) Have you had any other injuries in the past that were not work-related? If yes, please describe: 4) Have you received a medical discharge from the Armed Forces? [ ] yes [ ] no 5) Please rate your pain level on the scale below: 0 = no pain 10 = worst pain Now: Average: Most Intense: ) My pain is worse when I (please X all that apply): [ ] Cough or sneeze [ ] Breathe In [ ] Sit [ ] Bend my low back [ ] Bend my neck [ ] Turn my head [ ] Walk [ ] Lift [ ] Push [ ] Pull [ ] Stand [ ] Other: 7) What makes your pain better? 8) Do you have weakness? [ ] yes [ ] no Where? 9) Do you have areas of numbness or tingling? [ ] yes [ ] no Where? 10) Do you have difficulty controlling your bowels or bladder? [ ] yes [ ] no 11) Have you had any of the following procedures done to treat your pain? (Please X all that apply): [ ] physical therapy [ ] bed rest [ ] psychological counseling [ ] ice [ ] epidural steroid injections [ ] heat [ ] facet joint injections [ ] nerve blocks [ ] trigger point injections [ ] acupuncture [ ] chiropractic therapy [ ] surgery
3 [ ] anti-inflammatory medication [ ] traction [ ] joint injection(s) [ ] steroids [ ] TENS (transcutaneous electrical nerve stimulation) 12) Have any of the above-listed procedures decreased your pain? [ ] yes [ ] no 13) List all medications you have used in the past to treat your pain. 14) List all diagnostic tests you have had and specify which body part was tested: [ ] MRI [ ] Bone Scan [ ] X-ray [ ] CT scan [ ] Myelogram [ ] Discogram [ ] EMG/nerve conduction studies [ ] Other 15) Have you had any of the following medical illnesses? [ ] Depression [ ] Peptic Ulcer Disease [ ] Gastritis [ ] Anxiety [ ] Diabetes [ ] Shingles [ ] Pulmonary Embolus [ ] Pancreatitis [ ] Syphilis [ ] Major Blood Vessel [ ] Thyroid Disease [ ] Lupus [ ] Congestive Heart Failure [ ] Kidney Disease [ ] Asthma [ ] Bleeding Tendency [ ] Emphysema [ ] Peripheral Vascular Disease [ ] Abnormal Heart Rhythm [ ] Heart Attack [ ] High Cholesterol [ ] High Blood Pressure [ ] Liver Disease [ ] Parkinson s Disease [ ] Interstitial Cystitis. [ ] Hepatitis [ ] Restless Leg Syndrome [ ] Chronic Bronchitis [ ] Tuberculosis [ ] Psoriasis [ ] Rheumatoid Arthritis [ ] Osteoarthritis [ ] Migraine Headaches [ ] Stroke [ ] Chicken Pox [ ] Tension Headache [ ] Kidney Stones [ ] Multiple Sclerosis [ ] Carpal Tunnel Syndrome [ ]right [ ]left [ ] Other Nervous System Diseases [ ] Osteoporosis [ ] Deep Venous Thrombosis [ ] Urinary Tract Infections [ ] Meningitis [ ] Endometriosis [ ] Seizures/Epilepsy [ ] Gout [ ] Sleep Apnea [ ] Cancer. What type? [ ] Radiation [ ] Chemotherapy [ ] Whiplash [ ] Concussion [ ] Peripheral Neuropathy 16) Have you had any major illnesses that required hospitalization? [ ] yes [ ] no Describe: 17) Have you had chronic exposure to any toxins? 18) List all surgeries you have had in the past: 19) List all medications you are currently taking, including nonprescription medications continue on the back of this page if necessary.
4 20) List all drugs to which you are allergic: 21) List all drugs to which you have had a bad reaction: _ 22) Have you ever used prescribed controlled drugs before? 23) Have you ever been to a pain doctor before? 24) Do you have a past history of chemical/substance abuse, including alcohol, illicit and/or illicit drugs? REVIEW OF SYSTEMS 25) Please list any problems that you NOW HAVE with the following body systems: Ear/Nose/Throat: ( ) Denied Eyes: ( ) Denied Lungs: ( ) Denied Liver: ( ) Denied G-I Tract (Stomach, Intestines, Bowels, Etc.): ( ) Denied Kidney/Bladder: ( ) Denied [Women] Reproductive System: ( ) Denied Skin: ( ) Denied Neurological: ( ) Denied Heart/Circulation: ( ) Denied Psychological: ( ) Denied _ FAMILY HISTORY: 26) Has anyone in your family experienced similar pain? [ ] yes [ ] no SOCIAL HISTORY: 27) What is your marital status? [ ] single [ ] married [ ] divorced [ ] separated [ ] widowed 28) Do you have children? [ ] yes [ ] no How many? Ages: 29) Do you smoke? [ ] yes [ ] no How many packs per day? How many years? 30) Do you drink alcohol on a regular basis? [ ] yes [ ] no If yes, how many drinks per day of what type? 31) Do you use any street drugs? [ ] yes [ ] no
5 32) What is your highest level of education? 33) Has pain affected your: Sleep [ ] yes [ ] no Exercise [ ] yes [ ] no Mood [ ] yes [ ] no Appetite [ ] yes [ ] no Sexual Activity [ ] yes [ ] no OCCUPATIONAL HISTORY: 34) Are you currently employed? [ ] no [ ] full time [ ] part time [ ] homemaker [ ] retired 35) What is your occupation? 36) If you are unemployed or employed part time, is this due to your pain? [ ] yes [ ] no 37) Is there currently any personal injury litigation due to your pain? [ ] yes [ ] no 38) Are you receiving any disability payments due to your pain? [ ] yes [ ] no If so, what type ( X all that apply): [ ] Social Security [ ] State Disability [ ] Private [ ] Workers Compensation 39) If female, is there any way you could be pregnant? [ ] yes [ ] no 40) Are you currently receiving chiropractic physical therapy? [ ] yes [ ] no If yes, where and how many days per week? 41) Are you currently receiving physical therapy? [ ] yes [ ] no If yes, where and how many days per week? 42) Have you had any work-related injuries in the past? [ ] yes [ ] no 43) Is your current pain due to a work-related injury? [ ] yes [ ] no 44) Who is your primary care physician? 45) Which doctor referred you to us? 46) If you were not referred, how did you hear about us? 47) Do you have an Advance Healthcare Directive? [ ] Yes [ ] No If yes, please provide us with a copy
6 CERTIFICATION I certify that I have answered truthfully all the questions, and have not knowingly withheld any information concerning any of the above problems, either past or present. Your Signature Witness BECAUSE DR. VELIZ IS A SOLO MEDICAL PRACTITIONER WITH NO OTHER MEDICAL DOCTORS, PHYSICIAN ASSISTANTS OR NURSE PRACTITIONERS, HE CANNOT DO ANY MORE OPIATE OR NARCOTIC MEDICATION MANAGEMENT. DR. VELIZ WILL MAKE RECOMMENDATIONS FOR YOUR PRIMARY CARE PHYSICIAN TO FILL YOUR OPIATES OR NARCOTICS. I agree that Dr. Jose Veliz will not provide narcotic medication management for me. I agree that my narcotic medications will be filled by my primary care physician OR other prescribing specialist not including Dr. Jose Veliz. Signature of Patient THANK YOU! Signature of Reviewing Physician
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ASSIGNMENT OF BENEFITS PATIENT NAME: First Middle Last PHONE NUMBER: Home: Work: HOME ADDRESS: City ZIP AGE: DOB: SSN: Status EMAIL ADDRESS: PATIENT EMPLOYER: How long? Occupation SPOUSE S EMPLOYER: Spouse
RHEUMATOLOGY PATIENT HISTORY FORM
!! RAMOS RHEUMATOLOGY, PC RHEUMATOLOGY PATIENT HISTORY FORM Date: / / NAME: Birthdate: / / Last First M. I. Age: Sex: F M Marital status: Never married Married Divorced Separated Widowed Partnered/significant
Mercy MS Center New Patient Information
Mercy MS Center New Patient Information Last Name: First Name: DOB: MULTIPLE SCLEROSIS HISTORY Reason for clinic visit: I have been diagnosed with MS or NMO (Date diagnosed ) I have not been diagnosed
Pacific Coast Medical Group, PLLC dba Bellevue Pain Institute NE 8th St. Ste. 200 Bellevue, WA
PATIENT INFORMATION PHONE NUMBERS Date: Sex: M F Home: Work: Name: Address: City: State: Zip: Single Married Widowed Separated Divorced Cell: AT&T Verz T-Mob Nextel Virgin Sprint Email: Best time to reach
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
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
CORNERSTONE PAIN MANAGEMENT
SECONDARY INSURANCE PRIMARY INSURANCE CORNERSTONE PAIN MANAGEMENT PATIENT INFORMATION First Name: Dr. Mr. Mrs. Ms. Miss MI: Last Name: Social Security: Age: Date of Birth: Gender: Address: City: State:
Chayapathy Jollu, MD Board Certified in Physical Medicine and Rehabilitation Patient Initial Pain Questionnaire
Patient Initial Pain Questionnaire Date: Last Name: First Name: Middle Name: Age: Gender: M F Right handed Left handed Referring Physician: Primary Care Physician: Address: Address: Phone: Phone: Fax:
Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:
We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full
MEDICAL INFORMATION. SECTION 1: Pharmacy Information. Pharmacy Name and Address: Pharmacy Phone Number: SECTION 2: Social History
MEDICAL INFORMATION TODAY S DATE: SOCIAL SECURITY NUMBER: PATIENT NAME: BIRTHDAY: HEIGHT: WEIGHT: AGE: WHO REFERRED YOU? RACE: PRIMARY CARE PHYSICIAN: SEX: DOCTOR S ADDRESS: SECTION 1: Pharmacy Information
Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
DEPARTMENT OF NEUROSURGERY Spine Center New Patient Intake Form
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
PAIN TREATMENT CENTER
PAIN TREATMENT CENTER Name Date Age Occupation Referring Doctor Have you ever been a patient of a Pain Clinic or Center? Yes No If yes where: When did you first notice symptoms of your pain problem? Date
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
New Patient Form Welcome!
New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had