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. Phone: (800) 885-PAIN -or- (904) 374-0353 (return patients) Fax: (904) 503-0982 www.totalpainreliefclinic.com
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 POLICY NUMBER GROUP NUMBER PHONE NUMBER ( ) AUTO INSURANCE /SECOND INSURANCE NAME OF YOUR INSURANCE COMPANY: NAME OF POLICY CLAIM NUMBER POLICY NUMBER DATE OF ACCIDENT: ADJUSTER S NAME: PHONE NUMBER ( ) Do you have an attorney? Yes / No Attorney Name: EMPLOYER THOUGH WHICH YOU HAVE COVERAGE Attorney phone #: ( ) _ - _ I understand that I am financially responsible for all charges for the service rendered to me. I authorize release of any information necessary to process to my insurance claims and I hereby authorize payment of benefits due to me to be made directly to the doctor. I understand that Medicare may deny some charges and I will be responsible for payment. Co-payment. Co- pays are due at time of Service.
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 === 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 R L Circle your usual pain number (0-10) below: Describe how your symptoms started: L R 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? 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:
[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 Family History Explanation:
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: Fever or chills Weight loss Chest Pain Shortness of Breath Pain worse at night Trouble with sex life [The remaining portion of the 13-point Review of Systems is in the HPI and Medical History]