Ic ppw - 2014

The Offices of
Roland D. Reinhart, M.D.
(760) 341-2360
Date:______________
Dear: ___________________________________,
This letter is to formally welcome you to the Offices of Dr. Roland D. Reinhart and to remind you of your
upcoming new patient consultation appointment. Dr. Reinhart and his team of professionals are committed to
providing a comprehensive and compassionate approach to patients who are suffering from pain. Our practice
offers a systematic and focused approach that enables patients with chronic pain to lead an active and
productive lifestyle. “Now more then ever you have options to alleviate your pain.”
Just a reminder…

Your new patient consultation is scheduled for:

Day: ____________________ Date: __________________ Time: ________________

With: Roland Reinhart, M.D.
Location: Rancho Mirage

If you are unable to keep this appointment, please call us to reschedule. Also, please complete the following
enclosed information and bring it with you along with the additional items listed below.
Please bring:
1. A list of current medications, which includes dosage and frequency.

2. Your insurance card(s).
3. Any available records or reports that may pertain to your visit.
Should you have any further questions regarding your upcoming appointment, please call our office at (760) 341-2360. The Offices of
NEW PATIENT EVALUATION FORM
Roland D. Reinhart, M.D.
(760) 341-2360
In order to help us provide the best possible care for you at our office, we ask for your cooperation in providing
the following information. Please bring this form with you to your first appointment.
GENERAL INFORMATION
Date form completed _____/_____/_____

Patient Name:____________________________________________ Date of Birth:_____/_____/_____
Referred By:_______________________________ Primary Physician:______________________________
Emergency Contact:__________________________ Relationship:____________ Tel#:_________________
Preferred Pharmacy:______________ Location:_________________________ Tel #:_________________

Chief Complaint:_________________________________________________________________________

Circle any tests you have had for your current pain:
X-Ray CT Scan MRI Myelogram Bone Scan EMG Blood Tests Other:_____________________ CAUSE OF PAIN:_______________________________________________________________________

DURATION:
LOCATION OF YOUR PAIN
Date your pain first occurred: _________________ Unknown: On the picture color in all your areas of pain

TIMING:
The initial onset of pain was:
____Gradual ____Sudden ____Unknown
ACTIVITIES OF DAILY LIVING SIGNIFICANTLY
IMPACTED BY PAIN:
□ Bathing and showering
SEVERITY OF PAIN:
Circle how you would describe your pain during the past week:
None Mild Moderate Horrible Excruciating

HISTO
Over tRhY
at iSt s worst:________ Pain at its best:________
Pain right at this moment:________
Age________ Race_______________ Sex_____ Who is completing the paperwork______________________
Patient Nam P
e: LEASE DRAW WHERE YOU
___________________________RD PA
The Offices of
Roland D. Reinhart, M.D.
(760) 341-2360
QUALITY OF PAIN: The questions below refer ONLY to the area of pain that you are coming to our clinic for at this time
Circle the word that better describes the pattern of pain:

Circle the word(s) that best describe what your pain feels like:
Knifelike Spasm Jabbing Throbbing Stabbing
Cramping Shooting Aching Deep Pressure Numbness Tingling

ASSOCIATED SIGNS AND SYMPTOMS: Mark all that apply.

____Headache ____ Swelling ____ Light-headedness ____ Nausea ____ Vomiting ____ Fatigue ____ Pain that wakes you up
____ Pain with the first steps in the morning ____ Pain after periods of resting ____ Weakness ____ Loss of bowel control
____ Loss of bladder control ____ Fever/Chills ____ Unexplained weight loss-How many pounds? ____lbs.
____Other:______________________________________________________________________________________________

____Stiffness in:_________________________________Right / Left

____Tenderness in:_______________________________ Right / Left
____Weakness in:________________________________ Right / Left
MODIFYING FACTORS:
Circle which makes your pain better:
Activity Sitting Standing Lying Down Rest Medication Heat Ice Changing Positions Stretching
Movement Walking No Movement Other:________________________________

Circle which makes your pain worse:
Walking Sitting Standing Lying Down Heat Ice Cold Weather Activity Rest Medication
Changing Positions Lack of Activity Bending Lifting Twisting Turning Movement Lights Stress
Other (Explain):_________________________________________________________________________________________
MEDICATIONS: Please list all medications you currently use, the medication strength and how often you take it.
Name of Medication
Strength/MG
Frequency
The Offices of
Roland D. Reinhart, M.D.
(760) 341-2360
ALLERGIES: Please list any allergies to medications and the reaction experienced.
Name of Medication
Reaction Experienced
Please list any other allergies that may be pertinent, such as Latex, IVP dye, etc.______________________________

__________________________________________________________________________________________________

PAST MEDICAL HISTORY
Have YOU had any of the following conditions? (Check all that apply)
( ) Asthma ( ) Bleeding Disorder ( ) Cancer: What Area ___________________ ( ) Diabetes ( ) Emphysema ( ) Heart Attack ( ) Heart Disease ( ) High Blood Pressure ( ) Kidney Disease ( ) Mental Illness ( ) Seizure Disorder ( ) Stroke ( ) Suicidal Thoughts ( ) Thyroid Disease ( ) Tuberculosis ( ) Other_________________________ PAST SURGICAL HISTORY
Please list all previous surgeries:
Date (Month/Year)
Procedure:
___________________________________________ __________________________________________________
___________________________________________ __________________________________________________ ___________________________________________ __________________________________________________ ___________________________________________ __________________________________________________ ___________________________________________ __________________________________________________ SOCIAL HISTORY

Do you drink alcohol? Never Rarely Occasionally Often Socially

Do you drink caffeine? Never Rarely Occasionally Often

Do you smoke? YES / NO If yes, How many per day? ______ How many years have you smoked?______

Educational Background (highest grade completed):
( ) Junior High ( ) High School ( ) Technical or Business School ( ) College Degree ( ) Graduate Degree Marital Status / Family:
( ) Single
( ) Divorced How Long?_________________ Who lives with you?________________________________________________________________________________
Occupation:__________________________ ( ) Full Time ( ) Part Time ( ) Retired? How Long_________
( ) Disabled? How Long_________________________________ Have you ever been treated for depression? YES / NO If yes, when?_______________________________________
Have you been physically abused? YES / NO
Have you been emotionally abused? YES / NO
Are you under the care of a psychologist or psychiatrist? YES / NO If yes, who?____________________________
The Offices of
Roland D. Reinhart, M.D.
(760) 341-2360
FAMILY HISTORY
Mark if any (blood) relatives have had any of the following: Who had the condition?
Is the person living or deceased?
PAST TREATMENT HISTORY
Please check the following items you have tried and whether or not they helped decrease your pain:
( ) Acupuncture-Did it help? Y/N
( ) Biofeedback-Did it help? Y/N
( ) Chiropractor-Did it help? Y/N
( ) Spinal Cord Stimulator-Did it help? Y/N
( ) Epidurals-Did it help? Y/N
( ) Heat-Did it help? Y/N
( ) Home Exercises-Did it help? Y/N
( ) Ice-Did it help? Y/N
( ) Hypnosis-Did it help? Y/N
( ) Massage-Did it help? Y/N
( ) Intraspinal Pump-Did it help? Y/N
( ) Steroid Injections-Did it help? Y/N
( ) Physical Therapy-Did it help? Y/N
( ) TENS Unit-Did it help? Y/N
( ) Surgery-Did it help? Y/N
( ) Botox Injections – Did it help? Y/N
( ) Trigger Point Injections-Did it help? Y/N
( ) Other____________________-Did it help? Y/N
The Offices of
Roland D. Reinhart, M.D.
(760) 341-2360
PAST MEDICATION HISTORY
Please check the following medications you have tried and whether or not they helped decrease your pain:
ANTI-INFLAMMATORIES
MUSCLE RELAXERS
( ) Advil-Did it help? Y/N
( ) Flexeril-Did it help? Y/N
( ) Alieve-Did it help? Y/N
( ) Soma-Did it help? Y/N
( ) Celebrex-Did it help? Y/N
( ) Zanaflex-Did it help? Y/N
( ) Ibuprofen-Did it help? Y/N
( ) Skelaxin-Did it help? Y/N
( ) Mobic-Did it help? Y/N
( ) Ultram-Did it help? Y/N
( ) Other____________________-Did it help? Y/N
( ) Other_________________-Did it help? Y/N
( ) Other____________________-Did it help? Y/N
( ) Other____________________-Did it help? Y/N
NARCOTICS
NARCOTICS
( ) Actiq-Did it help? Y/N
( ) OxyIR-Did it help? Y/N
( ) Darvocet-Did it help? Y/N
( ) Percocet-Did it help? Y/N
( ) Demerol-Did it help? Y/N
( ) Percodan-Did it help? Y/N
( ) Dilaudid-Did it help? Y/N
( ) Roxicodone-Did it help? Y/N
( ) Duragesic Patch-Did it help? Y/N
( ) Vicodin-Did it help? Y/N
( ) Morphine-Did it help? Y/N
( ) Methadone-Did it help? Y/N
( ) Norco-Did it help? Y/N
( ) Oxycontin-Did it help? Y/N
( ) Other_________________-Did it help? Y/N
( ) Other_________________-Did it help? Y/N
( ) Other_________________-Did it help? Y/N
( ) Other_________________-Did it help? Y/N
I, the undersigned, have completed this form to the best of my knowledge. The information that I have provided is true and accurate to the best of my knowledge. I understand that this information is used in the care and treatment plan while under the care of all physicians and staff at The Offices of Roland D. Reinhart, M.D. __________________________________________ The Offices of
Roland D. Reinhart, M.D.
(760) 341-2360
REVIEW OF SYSTEMS DATE:________________________________

Please review the following list and mark any that apply to you for today’s visit:

Constitutional
Respiratory
Neurological
Gastrointestinal
Ear, Nose, Throat
Psychiatric
Genitourinary
Endocrinology
Cardiovascular
Musculoskeletal
Hematologic/Lymphatic
Allergy / Immunology
The Offices of
Roland D. Reinhart, M.D.
(760) 341-2360
Additional Information Required by the U.S. Government
Have you received an influenza immunization either during last flu season (September 2011 - February 2012) or
this flu season (September 2012 - February 2013)? Y / N
Date/Approximate Date: ______________________
Have you ever received a pneumococcal vaccination (for pneumonia)? Y / N
Date/Approximate Date: ______________________
Have you had a total colectomy (the entire colon removed)? Y / N
Date/Approximate Date: ______________________
Have you had a colonoscopy? Y / N
Date/Approximate Date: ______________________
Have you had a sigmoidoscopy (partial colonoscopy)? Y / N
Date/Approximate Date: ______________________

Source: http://www.advancedpainmanagement.org/iccpprwrk1.pdf