Locations: Even though we at Central Texas Pain Center are

Transcription

Locations: Even though we at Central Texas Pain Center are
Locations:
North Austin
San Marcos
Seguin
12414 Alderbrook Ste 101
Austin, TX 78758
512-498-1029
601 A Leah Ave.
San Marcos, TX 78666
512-498-1029
205 N King St.
Seguin, TX 78155
830-627-3800
New Braunfels
San Antonio
Killeen
213 Hunters Village
New Braunfels, TX 78132
830-627-3800
4410 Medical Dr. Ste 390
San Antonio, TX 78229
210-614-9955
3202 S W.S. Young
Ste. 102
Killeen, TX 76542
254-247-3322
Seguin
Waco
515 N. King St. Ste 103
Seguin, TX 78155
830-627-3800
205 Woodhew Dr. Ste 203
Waco, TX 76712
254-732-6632
South Austin
4316 James Casey St.
Bldg. B Ste.200
Austin, TX 78745
512-498-1029
Even though we at Central Texas Pain Center are committed to compassionate care, we must
exercise proper due diligence when prescribing opioid analgesics for chronic pain. Prescription drug
abuse has reached epidemic proportions in our society. Therefore, our clinic policy is that an
appropriate workup must be completed prior to the dispensing of an opioid prescription. This workup
will include review of previous pharmacy/clinic records, evaluation by diagnostic and laboratory tests,
and acceptable completion of a urine drug screen yielding expected results. Common examples of
opioid analgesics include hydrocodone, morphine, oxycodone, fentanyl, opana, and methadone.
Prescriptions for these medications will not be given at an initial visit.

Please bring your driver’s license and insurance cards along with your completed new patient
paperwork for your scheduled appointment. Payment for services are expected at the time of
service (co-pays, co-insurance, private pay). We accept cash, check, money order, and credit
cards (Visa, American Express, MasterCard, and Discover).

If you have been instructed to obtain imaging reports and/or films by our staff, please
bring them to your appointment. Our office requires these as part of your consultation.
If we do not have your films at the time of your appointment, you may be rescheduled.

Your initial visit at Central Texas Pain Center is a consultation. If a doctor referred you for an
injection, you must be seen for an office visit. Procedures are scheduled after the initial
consultation.

If English is your second language, please make arrangements for someone to accompany
you to your visit who can translate in order to provide you with the best healthcare service. We
want you to fully understand your diagnosis and prognosis, and have any questions you may
have answered.
We wish to make your visit as comfortable as possible, so please do not hesitate to contact us if you
have any questions at the numbers listed above.
NAME: ___________________________________________________ DATE OF BIRTH: __________________________
NEW PATIENT INTAKE
NAME: __________________________________________________DATE OF BIRTH: __________________GENDER:____M____F
ADDRESS: __________________________________________________________________________________________________
CITY: _____________________________________________________ STATE: __________________ ZIP: ____________________
HOME PHONE: _______________________CELL PHONE: _______________________WORK PHONE: ______________________
SSN: ____________________________________________DRIVERS LICENSE #:_________________________________________
ETHNICITY: □Hispanic or Latino
RACE: □American Indian
□Not Hispanic or Latino
PREFERRED LANGUAGE: ____________________________
□Asian □Black or African American □Native Hawaiian or Other Pacific Islander □White □Other
RELIGION: ______________________________________________ EDUCATION: __________________________________
EMAIL: ______________________________________________MARITAL STATUS:
WHAT IS YOUR PREFERRED METHOD OF COMUNICATION?
□Married □Widowed □Single □Divorced
□Home phone □Cell Phone □Work Phone □E-Mail
REFERRING PHYSICIAN: ______________________________PRIMARY CARE PHYSICIAN: _______________________________
OTHER PHYSICIANS: _________________________________________________________________________________________
EMERGENCY CONTACT: _______________________________________ RELATIONSHIP: ________________________________
EMERGENCY PHONE: _______________________________________
PHONE TYPE: ___________________________
RESPONSIBLE PARTY INFORMATION
NAME: __________________________________________________________DATE OF BIRTH: _____________________________
ADDRESS: __________________________________________________________________________________________________
PHONE: _____________________________SSN:________________________________RELATIONSHIP:_____________________
EMPLOYER: ______________________________________________________EMPLOYER PHONE: _________________________
INSURANCE or ATTORNEY (if applicable) INFORMATION
INSURANCE COMPANY: ________________________________________________
Please provide card to front desk.
INSURED’S NAME: ________________________________________________DATE OF BIRTH: ____________________________
INSURED’S SSN: ____________________________________RELATIONSHIP TO PATIENT: □SELF □SPOUSE □DEPENDENT
ATTORNEY NAME: _________________________________________ ATTORNEY PHONE: ___________________________
ATTORNEY ADDRESS: _______________________________________________________________________________________
NAME: ___________________________________________________ DATE OF BIRTH: __________________________
Clinic Policies
Initials ________Payment is due at the time services are rendered. I understand that if I have insurance that I am the
responsible party, and that having insurance does not guarantee payment of the services rendered to me. I authorize
submission of my claim to the insurance company listed above.
Initials ________If you are unable to make an appointment please call within 24 hours prior to your appointment time
to reschedule. If you fail to notify our office prior to missing your scheduled appointment you will be charged a NO SHOW
fee of $25 for an office visit and $50 for a procedure. Frequent NO SHOWS may result in a release from the practice.
Initials ________Permission for treatment: I hereby authorize physician and assistants for the care of the patient
named on this record to administer treatment as may be deemed necessary including examinations of treatments that
may be ordered to be performed by the clinical personnel. I acknowledge that no guarantees have been made to me to
the result of examinations or treatments to be performed.
Acknowledgement of Review of Notice of Privacy Practices
I have reviewed this office’s notice of privacy practices, which explains how my medical information
will be used and disclosed. I understand that I am entitled to receive a copy of this document.
______________________________________________
Signature of Patient or Representative
____________________________________________
Date
______________________________________________
Witness (CTPC Employee)
______________________________________________
Description of witness authority
***Please list the name of any person(s) you wish to have access to your medical information,
including portal access:
Name: ________________________________________Relationship:________________________
Name: ________________________________________Relationship:________________________
NAME: ___________________________________________________ DATE OF BIRTH: __________________________
Medication Contract
The following outline is a medication contract between ____________ (patient) and the Central Texas
Pain Center (CTPC) concerning the usage of opioid analgesics. Examples of opioid analgesics include
hydrocodone, oxycodone, fentanyl, and morphine. Opioid analgesics may not completely relieve pain
symptoms. If the doctors of CTPC feel that you are not responding to therapy by showing substantial
improvement in function, your medications will be tapered. The following statements are relevant concerning
opioid analgesics.
1)
There are risks associated with chronic opioid therapy including but not limited to constipations, itching,
addiction, physical dependence, sexual dysfunction, nausea, vomiting, and drowsiness.
2) CTPC recommends that ALL patients on chronic opioids not participate in the operation of motor
vehicles or machinery. If the patient chooses to engage in these activities, CTPC bears no
responsibility for the outcome of such events.
3) The patient will use only one pharmacy and will notify us with the name of the chosen pharmacy.
4) Unannounced urine drug screenings will happen during the course of treatment and you are expected
to comply. Positive results of illicit drugs, excessive alcohol or negative results of the prescribed drug
may result in termination from the clinic.
In addition opioid analgesics will NOT be prescribed on your initial visit because an acceptable urine
screen and review of pharmacy records must occur prior to starting these medications
5) Our clinic must be notified THREE BUSINESS DAYS prior to an anticipated refill date.
6) Lost or stolen medications will not be replaced for ANY REASON. In addition refills will not be given for
any reason after hours or on weekends. Early refills will only be given if authorized by the physician or
if a dosage is increased.
7) Patients will not seek opioid analgesic from any other physician for treatment of their chronic condition.
This policy in no way prevents a patient from seeking acute care for acute problems.
8) If you are coming in for an early office visit, you will need to bring all unused opioids to your
appointment
The patient acknowledges that he/she has read this contract and agrees to abide by its regulations.
______________________ Patient signature
______________________
Date
____________________ CTPC representative
NAME: ___________________________________________________ DATE OF BIRTH: __________________________
PAST MEDICAL HISTORY:
Please indicate if you have suffered any of the following medical conditions. Also, state the year when these
occurred.
_____AIDS or HIV
_____Arthritis
_____Asthma
_____Cancer
_____Chronic skin disease
_____Depression
_____Diabetes
_____Emphysema
_____Fibromyalgia
_____Gall bladder
_____Gonorrhea
_____Gout
_____Headaches/migraines
_____Heart disease/attack
_____Heart failure
_____Heart murmur
_____Hepatitis
_____Herpes infection
_____High blood pressure
_____Hormone problems
_____Insomnia
_____Irregular heart beats
_____Jaundice
_____Kidney disease
_____Kidney stones
_____Liver disease
_____Lupus
_____Menopause
_____Multiple sclerosis
_____Nervous breakdown
_____Other blood abnormality
_____Other venereal disease
_____Panic attacks
_____Peptic ulcer disease
_____Peripheral vascular disease
_____Pneumonia
_____Prostate enlargement
_____Rheumatic heart
_____Schizophrenia/bipolar
_____Seizures/convulsions
_____Shingles
_____Stroke
_____Syphilis
_____Thyroid
_____Tuberculosis
_____Urinary infection
_____Other:________________________
__________________________________
__________________________________
PAST SURGICAL HISTORY

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
FAMILY HISTORY:
Please list any disease, illness, or ailments in your IMMEDIATE FAMILY (i.e. mother-breast cancer,
father- diabetic, grandfather-heart disease).

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
NAME: ___________________________________________________ DATE OF BIRTH: __________________________
SOCIAL HISTORY
OCCUPATION: ______________________________________________________________
□Yes
□No
HOW MANY PACK(S) DAY? _______
DRINK ALCOHOL? □Yes
□No
IF YES HOW MUCH? _________________________
DO YOU SMOKE?
YEARS? ______
DO YOU USE ANY OTHER DRUG (Marijuana, Cocaine, etc.)? □Yes □No
If yes, which drug? _______________
MARITAL STATUS?
□Single
DO YOU LIVE ALONE?
□Yes
□Married □Divorced □Widowed
□No
If no, who do you live with? _______________
ALLERGIES ______________________________________________________________
PHARMACY NAME AND LOCATION _____________________________________
CURRENT MEDICATIONS
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
____________________
REVIEW OF SYSTEMSYSTEMS:
In the past few months, have you had any of the following symptoms or difficulties? If you
have any difficulty that bears further explanation, please indicate so and explain in the
additional notes section.
GENERAL:
Loss of appetite ……………… � YES
Fever or chills …………………. � YES
� NO
� NO
Recent weight loss ………………..…� YES
Low energy/Fatigue …………………� YES
� NO
� NO
EYES:
Blurred vision…………………… � YES
Loss of vision…………………… � YES
� NO
� NO
Double vision…………………………� YES
Eye Pain……………………………….� YES
� NO
� NO
HEAD/EARS/NOSE/THROAT:
Hoarseness……………………… � YES
Trouble swallowing………….….. � YES
� NO
� NO
Hearing loss……………………...……� YES
Ear pain…….…………………..….… � YES
� NO
� NO
NAME: ___________________________________________________ DATE OF BIRTH: __________________________
CARDIOVASCULAR:
Chest pain……………………..… � YES
Leg Swelling…………………..… � YES
Varicose Veins……………….…. □ YES
� NO
� NO
□NO
Palpitations………………………...….� YES
Orthopnea…………………….………..� YES
� NO
� NO
RESPIRATORY:
Shortness of breath ………….....� YES
Wheezing………………...……….� YES
� NO
� NO
Chronic cough ………………..……...� YES
� NO
GASTROINTESTINAL:
Nausea or vomiting…………..…..� YES
Blood in stool……………….……..� YES
Change in bowel habits……..……□YES
� NO
� NO
□NO
Heartburn…………….….…..………..� YES
Constipation…………….…..……….. �YES
Hemorrhoids……………….…………□YES
� NO
� NO
□ NO
KIDNEY/BLADDER/URINE:
Painful urination……………..…….� YES
Frequent Urination..……………....� YES
� NO
� NO
Blood in urine………………………..�YES
Change in urinary pattern……….….□YES
� NO
□NO
MUSCULOSKELETAL:
Significant pain/stiffness…………□ YES
□ NO
SKIN:
Rash………………………….……..� YES
Frequent Rashes……………….....� YES
� NO
� NO
Itching………………………...………� YES
� NO
NEUROLOGICAL
Tremor………………………………� YES
Seizures………………………...…..� YES
� NO
� NO
Dizziness………………………......…� YES
Tingling………………………………..� YES
� NO
� NO
PSYCHIATRIC:
Depression………………………....� YES
Drug/Alcohol addiction…….….….� YES
Difficulty with sexual activities..…. □YES
�NO
�NO
□NO
Suicidal Thoughts……………….…….� YES
Trouble sleeping (Insomnia)……...….� YES
� NO
� NO
ENDOCRINE:
Thyroid disease……………….……� YES
�NO
Heat/Cold intolerance……………..….� YES
� NO
HEMATOLOGICAL/LYMPHATIC:
Easy bruising…………………..…..� YES
�NO
Easy bleeding………….……….……..� YES
� NO
IMMUNOLOGIC:
Enlarged/ swollen lymph glands…□ YES
□NO
ADDITIONAL NOTES
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
NAME: ___________________________________________________ DATE OF BIRTH: __________________________
Pain Evaluation
Is there an ongoing lawsuit related to your visit today? � YES
� NO
Are you currently under worker’s compensation?
� NO
� YES
Location of your pain: __________________________________________
When did it start? _____________________________________________
What happened and when? (car accident, fall, nothing, etc.)
________________________________________________________________________________________
__________________________________________________________________________________
From scale of 0 to 10 (0=no pain and 10= severe pain) how bad is your pain today? _______ over the past 30 days what
was your average pain score? __________
What aggravates your pain? (Circle all that apply)
Sitting
Bending
Walking
Lying down
Leaning forward
Leaning back
Coughing/sneezing
Climbing upstairs
Going downstairs
Stretching
Rest
Heat
Cold
Medication
What makes your pain better? (Circle all that apply)
Sitting
Bending
Walking
Lying down
Leaning forward
Leaning back
Coughing/sneezing
Climbing upstairs
Going downstairs
If medication, which ones? ___________________________________________________________________________
What treatments have you tried in the past? When did you have these treatments? Did it
Treatments
Tried (yes or no)
When (year)
Chiropractor
______________
______________
Traction
______________
______________
Braces
______________
______________
Nerve Block
______________
______________
Physical Therapy
______________
______________
Hypnosis
______________
______________
Acupuncture
______________
______________
Biofeedback
______________
______________
Ice/heat Pack
______________
______________
Narcotics
______________
______________
Massage
______________
______________
Religious Counseling
______________
______________
Psychological Counseling
______________
______________
TENS/ Electrical Stimulation
______________
______________
Pain Medication
______________
______________
Surgery
______________
______________
help? (Indicate below)
Helped (yes or no)
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
______________
If you have had surgery for the pain, please list what kind, how many, when, and if it helped:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Which treatment above has helped you the most? _________________________________________________________
NAME: ___________________________________________________ DATE OF BIRTH: __________________________
Using the appropriate symbol, mark the area(s) on your body where you feel each of the sensations above.
Numbness Pins & Needles Burning
Aching
Stabbing
---------------- o o o o o o o o
^^^^^^ XXXXXXX
ΦΦΦΦΦΦ
Constant
Intermittent
Deep
Superficial
ccccccc
iiiiiiiiiiiiiiiii
ddddd
sssssssssss
How long can you be comfortable until pain increases?
Sitting
0 min
1-30 min
31-60 min
1 hour
Standing
0 min
1-30 min
31-60 min
1 hour
Resting or reclining
0 min
1-30 min
31-60 min
1 hour
How much time do you spend each day….?
Sitting
Less than 2 hrs
2-5 hrs
5-8 hrs
8-12 hrs
12 hrs
Standing
or walking
Less than 2 hrs
2-5 hrs
5-8 hrs
8-12 hrs
12 hrs

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