Microsoft word - 6623fd7d.doc


Please print clearly. Please complete all information so that your claim can be processed quickly and efficiently. Thank you!
Type of Injury: Back Leg Hip Neck Shoulder Arm Head Other: In Litigation: Yes NO Amount of Medical Benefits: Notice of Compensation Payable: Yes NO Relationship to Patient: Self / Spouse / Dependent If the patient is covered by another insurance policy, please complete the following information for coordination of benefits. This information will enable your insurance company to process your claim more quickly. Thank you! Relationship to Patient: Self / Spouse / Dependent I hereby assign, transfer, and set over to Center for Pain Control all of my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. Patient's Signature
OF YOUR SCHEDULED APPOINTMENT. If you are unable to fill them out yourself, please have your family
doctor give you a list of your medical history and current medication. You will need to arrive at our clinic 30
min prior to your appointment so we can assist you with this form.

What is your chief complaint? (example: 30% low back pain and 70% right leg pain)

When did it start? (example: 2months ago, or “7-26-03”)

Did you sustain any trauma immediately prior to the onset?

Is this work related or motor vehicle accident related?

Do you have an attorney? (Please provide their contact information)

Please describe the trauma.

Is the pain there constantly, intermittently, or both? (example: constant back pain with intermittent left leg pain)

Please describe the characteristics of your pain. (sharp vs. dull, burning, squeezing, throbbing, tingling, etc.)

What makes the pain worse? (Please circle)

Sitting Standing Walking Lying flat Bending over Lifting Others

What makes the pain better? (Please circle)
Sitting Standing Walking Lying flat Lifting Change Positions Other_________________ • What have you tried?

Dosage? H o w
l o n g ? Helpful?
Hydrocodone/APAP (Vicodin, Lortab, Norco) Oxycodone/APAP (Percocet, Endocet, Tylox, Roxicet) How long?
Reason stopped
Images (X-Ray, CT Scan, Bone Scan, etc.)
Study Date Where

Spine Injections

How long did it last?

Spine surgery

How long did it last?

Current Medication (Please list all meds including vitamins and OTC meds)
Medication Why

Are you allergic to any medications? (Please list and describe reaction)
Medication Reaction

IV contrast allergy?

Shellfish allergy?

Past Medical History (Please circle all)

AIDS / HIV Alcoholism Asthma Cancer Diabetes Emphysema Epilepsy Heart Disease
Hepatitis Herpes High Blood Pressure Multiple Sclerosis Pacemaker Seizures Stroke Thyroid Disorders Tuberculosis Fibromyalgia Depression Bipolar Disorder Schizophrenia Anxiety Disorder Other Psychiatric Issues Irritable Bowel Syndrome Chronic Pelvic Pain Migraine • Past Surgical History

Family History (Please list all significant family medical history such as bleeding problems (hemophilia), psychiatric
disorders, chronic pain, or any substance abuse)
Social history

Who do you live with now?
Are you currently working? If not, why not? Have you ever gone through rehab for drug or alcohol abuse? . Are you currently pregnant or plan to become pregnant? Have you ever been discharged from a doctor’s office because of noncompliance not following their directions?
Review of system

In the past month, have you experience any significant (Please circle all)

Weight loss/gain Fever/chills Changes in hearing/vision Dizziness Pass out Shortness of breath
Productive cough Chest pain Abdominal pain Diarrhea/constipation Weakness in the extremities Lost control of bowel/urinary functions Bleeding problems Rashes Depression Suicidal thoughts Homicidal thoughts Others ________________________ Please shade in on the drawings the areas where you feel pain.
Please rate the severity of your pain (mark “baseline” and “with exacerbation”) BASELINE

Who has treated you since the onset of the chief complaint?


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