CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) INTERNET **MEDICATION GUIDELINES PRIOR TO PROCEDURES
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1 CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) INTERNET MARTIN V.T. TON, MD Please call us at at least 24 hours in advance if you cannot make your appointment or this will result in a missed appointment charge. If the directions are unclear in any way, please do not hesitate to call us or visit our website at Thank you. Consultants in Pain Medicine, Inc. **MEDICATION GUIDELINES PRIOR TO PROCEDURES Please continue to take all your regular medications on the day of your appointment EXCEPT: Insulin- For morning appointments, DO NOT take insulin. For afternoon appointments take HALF your insulin. Oral diabetic agents (i.e.: Glucotrol, Amaryl, Diabeta, Micronase, Prandin, Diabinese, Glynase, Actos, Avandia, Rezulin) do not take. Anticoagulants Arixtra- stop 3 days prior to your procedure. Coumadin - stop 5 days prior to your procedure. Effient- stop 7 days prior to your procedure. Heparin - contact the office for specific directions. Plavix stop for 7 days prior to your procedure. Pradaxa- stop 3 days prior to your procedure. Ticlid (Ticlopidine)- stop for 14 days prior to your procedure. Xarelto (Rivaroxaban)- stop 24 hours prior to your procedure. ***Please note*** Nothing to eat or drink hours prior to your procedure. Someone present to drive you home. A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 1
2 Please contact our office or visit our website at if you have questions. From Interstates 64 and 664: DIRECTIONS TO 1080 MEDICAL OFFICE BUILDING Take 264E to exit 21B (2 nd of two First Colonial Rd exits). Once on First Colonial Rd, go about 1.5 miles to 1080 First Colonial Rd, located just past Virginia Beach General Hospital. Turn Right on Old Donation Parkway to access the parking lot. Use the second building entrance that is closest to the hospital. We are located on the 2 nd floor in Suite 201. From Chesapeake Bay Bridge Tunnel: After exiting bridge stay in right lane and follow sign towards Beaches/ Shore Dr. Turn left at light onto Shore Dr. Cross the Lesner Bridge. At the 4th traffic light turn right on N. Great Neck Rd. Travel approx. 5 miles and then turn left on First Colonial Rd (Exxon Station on corner). At 2 nd traffic light make a left onto Old Donation Parkway. Make the first right into the parking lot for the 1080 Medical Office Building. Use the second building entrance that is closest to the hospital. We are located on the 2 nd floor in Suite 201. A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 2
3 CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) MARTIN V.T. TON, MD Welcome to Consultants in Pain Medicine. Our physician, nurses and office staff hope to provide the best care possible with regard to your particular pain condition. Please fill out the enclosed questionnaire and answer all questions as completely as possible. Bring the completed forms to your appointment. (Please do not mail forms back to our office.) Your information is very important for proper treatment. Thank you. Consultants in Pain Medicine A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 3
4 Consultants in Pain Medicine, Inc. Please remember your fasting instructions, medication instructions, and to bring a driver. If you have not received this information, please call the office at or visit M.D. Signature Date Name: Age Height Weight Vitals: BP HR RR T SaO2 (will be completed at consultation) Please mark exactly where your pain is located: ALLERGY: When did you first notice your pain:_ Did you injure yourself, if so, what was the nature of your injury: Please describe what your pain feels like: Please mark any of the following that help describe your pain: Continuous Shooting Burning Sharp Tearing Off and On Dull Toothache Pulling Knife like PLEASE RATE YOUR PAIN BELOW What makes your pain WORSE: What makes your pain BETTER (mark ALL that apply): Rest Sitting Lying down Standing Nothing at all OTHER: A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 4
5 Please remember your fasting instructions, medication instructions, and to bring a driver. If you have not received this information, please call the office at or visit Do you have numbness in your arms or legs: No Yes Do you get tingling in your arms or legs: No Yes Do you have weakness in your arms or legs: No Yes Since your pain began, have you lost TOTAL control of your bowel or bladder? What medications have you taken BEFORE and stopped: Please indicate if you have had the following treatments for your pain: Epidural Steroid Injection Physical Therapy Chiropractor Acupuncture Trigger Point Injections OTHER: Which has helped your pain: Please indicate if you have had the following tests for your pain: MRI CT Scan Electromyelogram / EMG Bone Scan X-Rays Which other doctors do you see: Please mark all illnesses and disorders for which you are being treated or followed by a doctor: High Blood Pressure Diabetes Liver disease/hepatitis Heart Attack Underactive Thyroid Kidney Failure Congestive Heart Failure Overactive Thyroid Dialysis Irregular Heart Beat Tuberculosis Urine Infections Blocked Carotid Artery Pneumonia Kidney Stones Poor Circulation Asthma Seizures Cancer Heartburn Stroke Depression Acid Reflux HIV / AIDS OTHER: Please indicate all SURGERIES you have had: Lumbar /Back Heart Bypass Hysterectomy Neck Lung Caesarian Section Gallbladder Removal Aortic Aneurysm Repair Tubal Ligation Appendix Removal Carotid Artery Repair Brain Tonsil Removal Leg Artery Bypass Bowel Removal Bladder Kidney Stone Exploration of Bowel Broken Bone Cataract Prostate OTHER: A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 5
6 Please remember your fasting instructions, medication instructions, and to bring a driver. If you have not received this information, please call the office at or visit Please list all your MEDICATIONS and doses: DRUG DOSE Please list all drug ALLERGIES: Are you taking any BLOOD THINNING MEDICATIONS: Yes No What is your current occupation: Does it involve lifting or bending: Are you currently out of work on disability: Do you smoke, and how much: Do you consume alcohol and how much: Do you use recreational drugs: Is your mother or father deceased, if so from what illness and at what age: Do you have any brothers or sisters, please list their ages:_ Has anyone in your immediate family had a similar medical problem as the one that has brought you here today: Do you currently have any of these symptoms: Severe weight loss Seizure Very easy bruising Very high fever Stroke Excessive bleeding Night sweating Passing out Suicidal Thoughts Nausea / Vomiting Chest Pain Hallucinations Diarrhea Heart Palpitations Constipation Irregular Heartbeat Bloody Urine Chronic cough OTHER: Constant Urination Wheezing Painful Urination Bloody Sputum Additional Information: A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 6
7 .CONSULTANTS IN PAIN MEDICINE, INC. TELEPHONE (757) FAX (757) MARTIN V.T. TON, MD PATIENT: DOB: I hereby give Consultants in Pain Medicine my permission to request and receive any and all medical information from any previous or referring doctors. SIGNATURE DATE A SUBSIDIARY OF ATLANTIC ANESTHESIA, INC. 7
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Outpatient Rehabilitation Department Dear You have been referred to our office for an outpatient (Occupational Therapy, Physical Therapy, Speech Therapy) evaluation on at. Please arrive 15 minutes early
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
Diuretics: You may get diuretic medicine to help decrease swelling in your brain. This may help your brain get better blood flow.
Hemorrhagic Stroke GENERAL INFORMATION: What is a hemorrhagic stroke? A hemorrhagic stroke happens when a blood vessel in the brain bursts. This may happen if the blood vessel wall is weak, or sometimes
Rivaroxaban to prevent blood clots for patients who have a lower limb plaster cast. Information for patients Pharmacy
Rivaroxaban to prevent blood clots for patients who have a lower limb plaster cast Information for patients Pharmacy Your doctor has prescribed a tablet called rivaroxaban. This leaflet tells you about
Orthopedic Initial Questionnaire. Date: Weight:
Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete
Please fill out forms, sign where needed and bring with you to your first visit. If you have any questions please call the office at 212-751-8300.
Welcome to Manhattan Sports Medicine and the office of Dr. Kyle Worell. Before we get started please see all forms below: Personal History (Intake) Informed Consent Payments HIPPA Please fill out forms,
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH: DRIVERS LICENSE NUMBER: STATE: EMAIL ADDRESS: MARITAL STATUS: ( ) SINGLE ( )
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form
MODULE 1 SWAN NEW PATIENT INFORMATION FORM Universal New Patient Demographic Form Front Office Person calls in for a new patient appointment. o Never seen at SWAN o Previously Seen at SWAN The following
Atrial Fibrillation and Anticoagulants
York Teaching Hospital NHS Foundation Trust Atrial Fibrillation and Anticoagulants A guide to your diagnosis and treatment Information for patients, relatives and carers For more information, please contact:
Treatment with Apixaban
UW MEDICINE PATIENT EDUCATION Treatment with Apixaban Eliquis This handout explains the medicine apixaban, a drug that helps prevent blood clots. What is apixaban? Apixaban (brand name Eliquis) is an anticoagulant
Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340
Medicare Insurance Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning
Dr. David Y. Liao, D.O. Orthopedic Center, LLC. Release of Information
Release of Information The purpose of this form is to alert our office as to those family members and/or friends who may be scheduling or canceling appointments on your behalf and/or will need to have
Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D
Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION
PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT
Personal Injury Evaluation
Personal Injury Evaluation Patient Name: Date: Gender: M F Date of Birth: Social Security Number: Street Address: City: State: Zip: Home: Cell: Fax: Email: Employer: Emergency Contact: Phone: Phone: Medical
NEW PATIENT REGISTRATION
Title Mr / Mrs / Ms / Miss / Master / Dr Surname Given Names Address Postcode. Date of Birth. Age Occupation Telephone H.. M. W.. Next of Kin:. Tel:.. Referring Dr. Address.. Private Insurance YES / NO
Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address
PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic
Creekside Physical Therapy and Rehabilitation
Creekside Physical Therapy and Rehabilitation PATIENT INFORMATION Patient s Name: Social Security #: Age: Sex: M/ F Date of Birth: Email: Home Address: City: State: Zip: Telephone (Hm): Work: Mobile: Employer: