TOTAL PAIN RELIEF. Also bring your medication so that we can review them with you and help answer any question you may have.

Full text

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TOTAL PAIN RELIEF

Dear Pain Patient,

We would like to welcome you to our office. We strive to offer the best pain care with a multi-disciplinary approach. The

registration and medical history forms must be completed and returned to us within two weeks. Please keep your privacy

policy.

We will schedule your appointment once we have received all medical records, registration and medical history forms back

into our office. These are very important. Please call if you have any question or concerns.

Upon arriving in our office, you will meet our front office staff. They perform critical functions in welcoming you,

scheduling appointments, obtaining referrals and maintaining your medical records. They work hard to create a positive

experience for you. They insure our office follows: insurance and government regulations. They will ask if your

demographics or personal information is current. You will be asked for your:

Driver’s license

If applicable, insurance card (or insurance claim number for auto accident

If available, RECORDS:

Previous treating physicians Imaging studies: X-ray, CT scans, MRIs Surgery reports

EKGs Lab testing

Auto accident Police Report

Also bring your medication so that we can review them with you and help answer any question you may

have.

You are part of our team and together we can create a positive atmosphere with excellent communication, cooperation and

caring for each other. If you have question regarding your account or wish to speak to another person, our front office

person will help you. As part of the team, you can help us provide the best possible service experience for you. Our front

office personnel represent our practice and they are there to assist you. Thank you for your cooperation and for being part

of our team.

Sincerely

Terel S Newton M.D.

x

Phone: (800) 885-PAIN -or- (904) 374-0353 (return patients)

x

Fax: (904) 503-0982

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TOTAL PAIN RELIEF

TODAY’S DATE (MM/DD/YYYY) / /

FIRST AND LAST NAME REFERRING PHYSICIAN None DATE OF BIRTH / / AGE YRS GENDER: MALE FEMALE

ADDRESS LINE 1 SOCIAL SECURITY

ADDRESS LINE 2 EMPLOYER NAME

CITY STATE ZIP EMPLOYMENT STATUS

HOME PHONE: ( ) - WORK PHONE AND EXT ( ) - EXT CELL PHONE: ( )

-EMAIL ADDRESS: MARITAL STATUS:

DIVORCED MARRIED SINGLE SEPERATED WIDOW(ER) CHILDREN’S AGES:

STUDENT STATUS: FULL-TIME PART-TIME N/A

RACE ETHNICITY LANGUAGE (OTHER THAN ENGLISH)

EMERGENCY CONTACT PHONE# RELATIONSHIP

FAMILY PHYSICIAN: PHONE#

Do you have any ADVANCE DIRECTIVES? YES/ NO if yes, explain Insurance Information FIRST INSURANCE

NAME OF YOUR INSURANCE COMPANY:

NAME OF POLICY GROUP NUMBER _________

POLICY NUMBER PHONE NUMBER (_____) _________________ AUTO INSURANCE /SECOND INSURANCE

NAME OF YOUR INSURANCE COMPANY:

NAME OF POLICY POLICY NUMBER

CLAIM NUMBER DATE OF ACCIDENT: _____________________ ADJUSTER’S NAME: PHONE NUMBER ( )

Do you have an attorney? Yes / No Attorney Name: _____________________________ Attorney phone #:

( _____) _ _ _ - _ _ _ _ _

EMPLOYER THOUGH WHICH YOU HAVE COVERAGE

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Signed

Date

1

st

Name:____________ Last: ____________ DOB: ____ /____ /_____ Age: ___ yo Sex (Circle): M/F

Chief Complaint(s) [check and rate]:

Headache/Face __ /10 Low Back = __ /10

Neck Pain = __ /10 Joint Pain = __ /10

Mid-back Pain = __ /10 Other Pain = __ /10

_________________

HPI:

Draw your pain on the diagram. Use the symbols

to show the type of pain you feel.

Stabbing pain ///// Burning pain OOO Aching pain XXX Pins & needles VVV Numbness ===

Circle your usual pain number (0-10) below:

Describe how your symptoms started: ________

___________________________________

___________________________________

Current Medication: Type: tab, capsule,

patch, topical Dose: mg, mcg, other Times per day Reason taken/Effect Prescribing Provider

Allergies/Intolerance: Type of Reaction Currently Active or Inactive Office Staff Notes:

Medical History:

(CHECK

): AIDS/HIV ARTHRITIS / JOINT PAIN BLEEDING CANCER DIABETES INSULIN/INSULIN PUMP EPILEPSY/SEIZURES HEART PROBLEMS HEPATITIS High Blood Pressure MIGRAINES/Headaches MUSCLE DISEASES NERVE PROBLEMS PSYCHIATRIC PROBLEMS STOMACH STROKE/MINI-STROKES THYROID Explanation: ____________________________________________________________________________

VIP (VEHICLE INJURY PATIENT) / TRAUMA PATIENTS ONLY: Were you the driver? YES/ NO If NO, indicate: __ Front __Back seat Wearing a seatbelt? YES/ NO Lose consciousness? YES/ NO If yes, how long? ____________

Have you had this condition in the past? YES/NO Explain: ______ Do symptoms interfere with your day?

WORK SLEEP DAILY ROUTINE others ___________ Activities that are painful to perform:

SITTING STANDING WALKING LAYING DOWN OTHER: ________________________________________ Activities that you must perform at work/school or home:

SITTING STANDING WALKING OTHER

Check symptoms that have become apparent since the accident/injury: ○ Headache ○ Pain behind eyes ○ Sensitive to light ○ Visual changes ○ Anxiety ○ Nervousness ○ Irritability ○Depression ○ Fainting ○ Loss of balance ○ Ring/buzzing ears ○ Seizures ○ Forgetful ○ Loss of memory ○ Head seems too heavy ○ weakness ○ stiffness ○ Numbness/Pins & needles: _____ ○ Cold sweats ○ Cold hands/feet ○ Shortness of breath ○ Fatigue ○ Diarrhea ○ Constipation ○ Loss of Bladder/Bowel Control

Did you seek medical help immediately after the accident? ○ Yes ○ No If yes, how did you get there? ○ Someone else drove me

      ○ Drove own vehicle ○ Police ○ Ambulance Doctor/Hospital/Clinic:_________________________________

Date of first visit:_______________ Were you examined? ○ Yes ○ No

Were x-rays taken? ○ Yes ○ No Were MRIs taken? ○ Yes ○ No What diagnosis and treatment was given to you? _______________

L L

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[Failed Treatments (will be listed in your electronic records) with Medical Conditions]

PHYSICAL TREATMENTS FOR THE CURRENT CONDITION

TRIED?

WHEN?

WHERE?

HELPED?

Office Staff Notes:

PHYSICAL THERAPY

YES/NO

YES/NO

CHIROPRACTIC

YES/NO

YES/NO

REHABILITATION

YES/NO

YES/NO

Exercise/Education Program

YES/NO

YES/NO

Other:

YES/NO

YES/NO

What did you hope to accomplish today? _____________________________________________

INVENTERVENTIONAL TREATMENTS FOR THE CURRENT CONDITION

TRIED?

WHEN/WHERE

HELPED?

Office Staff Notes:

Trigger Point Injection

YES/NO

YES/NO

Facet Injection

YES/NO

YES/NO

Nerve Ablation/RFA

YES/NO

YES/NO

Sacroiliac Joint Injection

YES/NO

YES/NO

Nerve Block

YES/NO

YES/NO

Selective Nerve Block

YES/NO

YES/NO

EPIDURAL

YES/NO

YES/NO

DISCOGRAM

YES/NO

YES/NO

SURGERY

YES/NO

YES/NO

MEDICAL TREATMENT (TRIALS) FOR THE CURRENT CONDITION

Please list all medications that have been tried but FAILED to provide complete relief.

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Females only: OB/Gyn History:

Are you currently or trying to become pregnant? Yes/ No Date of last menstral period ___/___/____

Have you had menopause or had a hysterectomy (removal of uterus) or oophorectomy (ovary removal)? Yes/No

Surgical History/Hospitalization:

In order (OLDEST FIRST) LIST PREVIOUS SURGERIES/HOSPITALIZATIONS

DATE

SURGERY

DATE

SURGERY

1.

5.

2.

6.

3.

7.

4.

8.

Have you or anyone in your family ever had any problems with Anesthesia? If yes, Please explain.

o

History of difficult intubation (insertion of the breathing tube)

o

Adverse Reaction, Nausea or Vomiting after anesthesia

o

Relative with Malignant Hyperthermia (Genetic disease that causes a potentially fatal reaction to anesthesia)

If Yes, Explain: _________________________________________________________________________

Family History:

Do any family members (FATHER, MOTHER, SIBLINGS) have a history of:

AIDS/HIV ARTHRITIS / JOINT PAIN BLEEDING DISORDERS CANCER DIABETES INSULIN/INSULIN PUMP EPILEPSY/SEIZURES HEART PROBLEMS HEPATITIS HIGH BLOOD PRESSURE MIGRAINES/HEADACHES MUSCLE DISEASES NERVE PROBLEMS PSYCHIATRIC PROBLEMS STOMACH THYROID

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Social History:

Which of the following best describes you currently?

WORKING HOW LONG HAVE YOU BEEN AT THAT JOB? __________ NOT WORKING BECAUSE OF NECK OR BACK PROBLEM

NOT WORKING BECAUSE OF ANTOHER HELATH PROBLEM HOMEMAKER, RETIRED, OR UNEMPLOYED

DOES YOUR JOB REQUIRE LIFTING, STANDING, SITTING? ________________________________________________ EMPLOYER AT THE TIME OF INJURY: _______________________________________________________________ DO YOU SMOKE? YES/ NO (IF YES, HOW MANY PACKS PER DAY?) ___________________________________________ DO YOU DRINK ALCOHOL? YES/NO (IF YES, HOW MANY DAYS A WEEK?) ______________________________________ DO YOU CURRENTLY OR HAVE EVER USED ILLEGAL DRUGS? YES/NO (IF YES, EXPLAIN___________________________ Are you Right Handed or Left Handed? RIGHT / LEFT

HOW LONG CAN YOU … SIT __________ STAND ___________ WALK _____________

ROS:

Recently, have you had any:

Figure

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References

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Related subjects :