FlintHills Pain Management



PATIENT INFORMATIONToday’s Date_____________Name: Last:_______________________________First:___________________________MI:_________Sex M FDate of Birth:_____/_____/_____ Age:______ Social Security #____________________________Phone: Home:___________________________Cell:_________________________Work:__________________________E-Mail Address:_____________________________________________________________________________________Mailing Address:_______________________________________City:__________________St:_______Zip:____________Emergency Contact:_______________________________________________Phone:_____________________________Relationship:____________________________Physicians Information-Important, please complete:Referring Physician:_______________________________________Phone: ( )__________________________Address:_____________________________________City:______________________St:_____________Zip:__________IF DIFFERENT FROM ABOVEPrimary Care Physician:____________________________________Phone: ( )__________________________Address:_____________________________________City:______________________St:_____________Zip:__________INSURANCE INFORMATIONPrimary Insurance Name______________________________________________________________________________Insurance Subscriber____________________________________Date of Birth___________________________________Relation to Subscriber___________________Policy Number_________________________Group Number____________Effective Date______________________________Policy Holder’s Employer____________________________________Secondary Insurance Name___________________________________________________________________________Insurance Subscriber____________________________________Date of Birth___________________________________Relation to Subscriber___________________Policy Number_________________________Group Number____________Effective Date______________________________Policy Holder’s Employer____________________________________Worker’s Comp/Auto________________________________________________________________________________Case Manager/ Nurse: Name_________________________________________Phone:___________________________Case Number:______________________________________________________________________________________Send Bills to: Name________________________________________________________________________________Address: _____________________________________________________________________________ _____________________________________________________________________________ ____________________________________________________________________________SYMPTOMS for conditions you currently have or have had in the past ONE year. GENERAL EYE, EAR, NOSE, THROAT PSYCHIATRICChillsY NDifficulty SwallowingY NDisturbing ThoughtsY NFeverY NVision-flashesY NMemory LossY NDizzinessY NSinus ProblemsY NPsychatric DisordersY NFaintingY NNosebleedsY NHallocinationsY NDepressionY NPersistent CoughY N NEUROLOGICALForgetfulnessY NLoss of HearingY NLoss of ConsciousnessY NHeadacheY NRinging in EarsY NBlackoutsY NLoss of SleepY NCoughing BloodY NFaintingY NLoss of WeightY NTremorsY NNervousnessY NHead InjuryY NNumbnessY NStrokesY N MUSCLE/JOINT/BONE Pain, weakness, numbness in:GASTROINTESTINAL CARDIOVASCULARArmsY NHipsY NAppetite PoorY NChest PainY NBackY NLegsY NBloatingY NIrregular Heart BeatY NFeetY NHandsY NBowel ChangesY NLow Blood PressureY NNeckY NShoulderY NConstipationY NHigh Blood PressureY NBack ProblemsY NDiarrheaY NPoor CirculationY NMuscle CrampsY NExcessive ThirstY NRapid Heart BeatY NRestricted MotionY NLoss of Bowel ControlY NSwelling of LegsY NMuscle StiffnessY NHemorrhoidsY NVaricose VeinsY NJoint StiffnessY NIndigestionY NShort of BreathY NParalysisY NNauseaY NShort of Breath-SleepingY NRectal BleedingY NShort of Breath-ExertionY NStomach PainY NShort of Breath-Lying FlatY NVomitingY NThrombophelebitisY NVomiting BloodY NHeart MurmurY NCONDITIONS for conditions you currently have or have had in the past ONE year.AIDS/HIVY NChicken PoxY NKidney StonesY NProstate ProblemsY NAnginaY NDiabetesY NKidney DiseaseY NPsychiatric CareY NAnemiaY NEmphysema/COPDY NLiver DiseaseY NRheumatic FeverY NAnorexiaY NEpilepsy/SeizuresY NMeaslesY NScarlet FeverY NAppendicitisY NFibromyalgiaY NMeningitisY NStrokeY NArthritisY NGlaucomaY NMigraine HeadacheY NSyphilusY NAsthmaY NGoiterY NMitral Valve ProlapseY NSuicide AttemptY NBleeding DisordersY NGonorrheaY NCHFY NThyroid ProblemsY NBronchitisY NGoutY NMononucleosisY NTonsillitisY NBulimiaY NHeart DiseaseY NMultiple SclerosisY NTuberculosisY NCancerY NHepatitisY NMumpsY NTyphoid FeverY NCataractsY NHerniaY NPacemakerY NUlcersY NChronic Fatigue SyndromeY NHerpesY NParkinsons DiseaseY NUrinary Tract InfectionsY NChemical DependencyY NHigh Blood PressureY NPneumoniaY NVenereal DiseaseY NHigh CholesterolY NPolioY NPATIENT CONDITIONReason for Visit/current problem?______________________________________________________________________Using the symbols below, please draw in the location of your symptoms on the diagrams.XXXX = PainOOOO = Numbness/Tingling**** = AchingBETTERWORSENO CHANGEBendingCoughing/SneezingGeneral ActivityLeaning on cart while walkingLiftingLying DownSittingStandingStrainWalking508063500What position/activity makes your condition better or worse?CIRCLE THE NUMBER INDICATING THE USUAL DEGREE OF PAIN(0 means no pain, and 10 is the worst pain that you have ever felt in your life)012345678910HEALTH HABITS OCCUPATIONALCircle Y or N if you use the substances below Circle Y or N if your work exposes you to the following:& describe how much you use.Y NCaffeineY NStressY NHazardous MaterialY NTobaccoY NHeavy LiftingY NOtherY NRecreational DrugsY NAlcoholAre you currently working?YesNoIf released from work:By Whom?______________________________________ When?_____________________________________Why?_____________________________________________________________________________________________HEALTH HISTORYPlease indicate which DIAGNOSTIC TESTS you have had in evaluation of your main problem/complaint & date.TESTY/NDATETESTY/NDATEPlain X-RayEMG/NCTBone ScanMRICT ScanCT/MyelogramDiscogramOtherPlease mark which TREATMENTS you have had for your main problem and indicate whether they were helpful.TREATMENTXRELIEF?TREATMENTXRELIEF?Trigger Point InjectionsT.E.N.S. UnitEpidural Steroid InjectionsManipulationsPhysical TherapyTractionElectrical StimulationAqua TherapyUltrasoundWhirlpoolHeat PacksAcupunctureCold PacksOtherBraceHave you seen a Pain Management Specialist before – YESNOIf yes, when?____________________________Have you taken any of these drugs previously?DRUGYESNODRUGYESNOAleve (naproxyn)AspirinBextraArthrotecBaclofen (lioresal)CelebrexDarvocet (propoxyphene)DayproDemerol (Meperidine)DilaudidDurgesic Patches (fentanyl)Feldene (piroxicam)Flexeril (cyclobenzaprine)Ibuprofen (advil)Lortab (hydrocodone)MethadoneMotrinMS ContinMS IR (Morphine)Etodolac (lodine)NorcoNorflexOxycontinParafon FortePercodanPercocetPrednisoneRelafenRobaxin (methocarbamol)Skelaxin (metaxalone)Soma (carisoprodol)Talwin (pentazocine)ToradolTylenol #3VicodinUltram (tramadol)Ultracet (tramadol/APAP)ZanaflexKetoprofen (orudis)RoxicetHospitalizations/SurgeriesYEARHospital Treating PhysicianReason for Hospitalization/Surgery & OutcomeNotes:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
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