Kozmary Center for Pain Relief



right-132715Circle Today’s Provider:Steven Kozmary, MDTraci Farmer, APRNTeri Peacock, APRN00Circle Today’s Provider:Steven Kozmary, MDTraci Farmer, APRNTeri Peacock, APRN Patient Name: ________________________________Email Address: ________________________________Pharmacy Name: _________________________________ Pharmacy Phone: (____) ____________________Location of Pharmacy: ______________________________________________________________________Primary Care Physician: ________________________________Other provider(s) you would like to be kept informed about your treatment: _____________________________________Current Medications by Kozmary CenterMedicationStrength# per day1.____________________________________2.____________________________________3.____________________________________4.___________________________________Medication Prescribed by other providers:5.____________________________________6.____________________________________7.____________________________________ANY SIDE EFFECTS FROM THE MEDICATION Prescribed by Kozmary Center: (Circle)Constipation Itching Nausea Sedation Vomiting NONE Other:________________Circle if you are taking the following: PLAVIX TICLID COUDMADIN WARFARIN ASPIRINDo you currently drink alcohol? ? Yes ? No If yes, how much per day? _________________What is your chief pain problem? Since your last visit, is your pain?_________________________________________ ?Worse ?Same ?Better ?New, When:__________Other areas of pain: (in order of severity)1._______________________________________ ?Worse ?Same ?Better ?New, When:__________ 2._______________________________________?Worse ?Same ?Better ?New, When:__________3._______________________________________ ?Worse ?Same ?Better ?New, When:__________Issues you would like to discuss today?1._______________________________________2._______________________________________3._______________________________________Since your last visit:?Yes ?No Have you seen another pain management physician?When?: ______________________?Yes ?No Have you lost control of your bladder or bowel??Yes ?No Have you been in a drug rehab program or facility??Yes ?No Are your family or friends concerned about the amount of medications you are taking??Yes ?No Have you been hospitalized??Yes ?No I have used illegal drugs since my last appointment.?Yes ?No Have you obtained pain medications from any other physicians??Yes ?No Have you overdosed on your medications??Yes ?No Are you considering suicide as a way to stop the pain??Yes ?No Have you had any suicidal thoughts??Yes ?No Have you had a suicide attempt?3495675281305(Office Use Only)Copay: _______________ Payment Type: _______________Work CompLienEKGElective IM $__________Urinalysis: _________________________________________HT: _______________________ WT: ________________BP: _____________________/_____________________ Pulse: ___________________ O2:___________________00(Office Use Only)Copay: _______________ Payment Type: _______________Work CompLienEKGElective IM $__________Urinalysis: _________________________________________HT: _______________________ WT: ________________BP: _____________________/_____________________ Pulse: ___________________ O2:___________________66675281305(Office Use Only)Comments & Orders: Imaging: CTMRIX-RayUltra Sound Location: ______________________________________Referral: ______________________________________Procedures: ____________________________________Records Request: ________________________________Comments: _____________________________________ 00(Office Use Only)Comments & Orders: Imaging: CTMRIX-RayUltra Sound Location: ______________________________________Referral: ______________________________________Procedures: ____________________________________Records Request: ________________________________Comments: _____________________________________ ?Yes ?No Have you seen a psychiatrist or psychologist? Circle the words that best describe your pain today:Area: Stays in one place, moves around Explain: _________________________________________________________Nature: Burning, heavy, sharp, tingling, electric shock, throbbing, stabbing, gnawing, annoying, tiring, pins/needles, shooting, dull ache, cold, hot, cramping, punishing, cruel, exhaustingOther words to describe my pain: _______________________________________________________________________The following worsens my pain: Standing, lying, twisting, bending, coughing, sitting, walking, runningSeverity: Circle your pain level (1 = minimal pain, 10 = worst imaginable pain)Current level:1 2 3 4 5 6 7 8 9 10With medication:1 2 3 4 5 6 7 8 9 10Worst level:1 2 3 4 5 6 7 8 9 10Without medication:1 2 3 4 5 6 7 8 9 10Pain: Activities that increase my pain include: _____________________________________________________________Activities that decrease my pain include: _________________________________________________________________Time: Constant, intermittent, unpredictable, only at night, only during the day Explain: ___________________________________________________________________________________________At what time is the pain the worst? Early morning, midday, afternoon, evening, nightAre you working? ?Yes ?No Full duty Part time Light dutyAre you disabled or unable to work secondary to the pain? ?Yes ?No Body Pain Map: Draw the exact area where you feel pain today.3657600215900019431002159000Please complete Below:?Yes, Initial:___ I am responsible for all medications. They will not be replaced if lost, damaged, stolen, and spilled. If 28 day quantity is relinquished at pharmacy, prescription will not be rewritten or adjusted. ?Yes, Initial:___ I have signed a narcotic agreement with Dr. Kozmary. I am abiding by the terms of the agreement. I have not obtained any narcotic, sedative, anxiety or sleep medications from any other sources.?Yes, Initial:___ I understand that Dr. Kozmary may request a pharmacy profile which will show all prescriptions I have obtained in the past.?Yes, Initial:___ I understand that narcotic medications must be filled within 14 days from the date written. ?Yes Initial:____ The risks, benefits, and options of pain management therapy have been explained to me. I understand them and have no further questions.REVIEW OF SYSTEMSAllergic/Immunologic?Yes ?No Reactions to drugs __________________?Yes ?No Reaction to food ____________________?Yes ?No Reaction to insects __________________Cardiovascular?Yes ?No Chest pain?Yes ?No Edema?Yes ?No Heart murmurs?Yes ?No Hypertension?Yes ?No Palpitations?Yes ?No Shortness of breathIntegumentary System (Skin)?Yes ?No Dry skin?Yes ?No Rash?Yes ?No Sores/lesionsMusculoskeletal?Yes ?No Joint pain?Yes ?No Limited joint movement?Yes ?No Muscle pain?Yes ?No Numbness?Yes ?No Spine pain (neck, back)?Yes ?No Swelling?Yes ?No WeaknessEars/Nose/Throat?Yes ?No Headaches?Yes ?No Lightheadedness?Yes ?No Masses in thyroid?Yes ?No Nose bleeding?Yes ?No VertigoEndocrine?Yes ?No Diabetes; high blood sugar?Yes ?No Hormone therapy?Yes ?No Intolerance to heat or cold?Yes ?No Lymph node enlargement/tendernessEyes?Yes ?No Double vision?Yes ?No Vision changesGastrointestinal?Yes ?No Abdominal pain?Yes ?No Bloating?Yes ?No Changes in bowel habits?Yes ?No Constipation?Yes ?No Diarrhea?Yes ?No Food intolerance?Yes ?No Nausea?Yes ?No VomitingRespiratory?Yes ?No Cough?Yes ?No Coughing up blood?Yes ?No Shortness of breath?Yes ?No Wheezing?Yes ?No AsthmaGenitourinary?Yes ?No Blood in the urine?Yes ?No Decreased libido?Yes ?No Flank pain?Yes ?No Genital pain?Yes ?No Kidney stones?Yes ?No Pain with urination?Yes ?No Urinary frequency?Yes ?No Urinary urgencyNeurological?Yes ?No Burning in arms, legs, hands, or feet?Yes ?No Cold hands or feet?Yes ?No Discoloration in the hands or feet?Yes ?No Dizziness?Yes ?No Headache?Yes ?No Leg or foot cramps?Yes ?No Light headedness?Yes ?No Loss of balance?Yes ?No Loss of bladder control?Yes ?No Muscle pain?Yes ?No Muscle weakness?Yes ?No Numbness in arms, legs, hands, or feet?Yes ?No Pins/needles in arms, legs, hands, or feet?Yes ?No Problems with balance?Yes ?No SeizuresHematological?Yes ?No Bleeding diathesis?Yes ?No Easy bleeding?Yes ?No Easy bruising?Yes ?No Frequent nosebleeds?Yes ?No HemophiliaPsychological?Yes ?No Anxiety?Yes ?No Depression?Yes ?No Family discord?Yes ?No Financial difficulty?Yes ?No Increased stress?Yes ?No Marital difficulty?Yes ?No Work difficultiesConstitutional Systems?Yes ?No Awaken in the early morning?Yes ?No Chills?Yes ?No Daytime drowsiness?Yes ?No Fatigue?Yes ?No Fever?Yes ?No Normal activity and energy?Yes ?No Sleep continuity disturbances?Yes ?No Snoring?Yes ?No Trouble falling asleep?Yes ?No Trouble staying asleep?Yes ?No Weight gain or lossOswestry Disability Index (ODI)Please read: This daily questionnaire is designed to enable us to understand how much your condition has affected your ability to manage everyday activities. Please answer each section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but please just circle the one choice that closely describes your problem right now.Section 1 – Pain IntensityA I have no pain at the moment.B The pain is very mild at the moment.C The pain is moderate at the moment.D The pain is fairly severe at the moment.E The pain is very severe at the moment.F The pain is the worst imaginable at the moment.Section 6 – StandingA I can stand as long as I want without extra pain.B I can stand as long as I want but it gives me extra pain.C Pain prevents me from standing for more than 1 hour.D Pain prevents me from standing for more than ? hour.E Pain prevents me from standing for more than 10 minutes.F Pain prevents me from standing at all. Section 2 – Personal Care (Washing, Dressing, etc.)A I can look after myself normally without causing extra painB I can look after myself normally but it causes extra painC It is painful to look after myself and I am slow and carefulD I need some help but manage most of my personal careE I need help everyday in most aspects of self care.F I do not get dressed, wash with difficulty, and stay in bed.Section 7 – SleepingA My sleep is never disturbed by pain.B My sleep is occasionally disturbed by pain.C Because of pain, I get less than 6 hours of sleep.D Because of pain, I get less than 4 hours of sleep.E Because of pain, I get less than 2 hours of sleep.F Pain prevents me from sleeping at all.Section 3 – LiftingA I can lift heavy weights without extra pain.B I can lift heavy weights but it gives me extra pain.C Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (i.e. on a table).D Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.E I can lift only very light weights.F I cannot lift or carry anything at all.Section 8 – Sex LifeA My sex life is normal and causes no extra painB My sex life is normal but causes some extra pain.C My sex life is nearly normal but is very painful.D My sex life is severely restricted by pain.E My sex life is nearly absent because of pain.F Pain prevents any sex life at all.Section 4 – Walking A Pain does not prevent me from walking any distance.B Pain prevents me from walking more than 1 mile.C Pain prevents me from walking more than ? of a mile.D Pain prevents me from walking more than 100 yards.E I can only walk using a cane or crutches.F I am in bed most of the time and have to crawl to the toilet.Section 9 – Social LifeA My social life is normal and causes me no extra pain.B My social life is normal but increases the degree of pain.C Pain has no significant effect on my social life apart from limiting my more energetic interests, i.e. sports.D Pain has restricted my social life and I do not go out as often.E Pain has restricted social life to my home.F I have no social life because of pain.Section 5 – SittingA I can sit in any chair as long as I like.B I can sit in my favorite chair as long as I like.C Pain prevents me from sitting for more than 1 hour.D Pain prevents me from sitting for more than ? hour.E Pain prevents me from sitting for more than 10 minutes.F Pain prevents me from sitting at all.Section 10 – TravelingA I can travel anywhere without pain.B I can travel anywhere but it gives me extra pain.C Pain is bad but I manage journeys of over two hours.D Pain restricts me to journeys of less than 1 hour.E Pain restricts me to short, necessary journeys under 30 min.F Pain prevents me from traveling except to receive treatment.ODI ______ Raw Score (Staff to complete percent calculation)I have completed the questionnaire truthfully, accurately, and honestly to the best of my ability.Patient Signature: ____________________________________________ Date: ______________________________ ................
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