PainPA, LLC - Publicforms

Available Forms

1. NEW PATIENT REGISTRATION ALL MUST COMPLETE 2. HIPAA, TELEMEDICINE, NON-DISCLOSURE AGREEMENT & BILLING POLICIES 3. MEDICAL QUESTIONNAIRE ALL MUST COMPLETE 4. PAIN ASSESSMENT FORM ONLY COMPLETE IF APPLICABLE MEDICAL MARIJUANA CONSENT ONLY COMPLETE IF APPLICABLE NARCOTIC PRESCRIBING AGREEMENT ONLY DO IF APPLICABLE QUICK CONTACT US RECORD RELEASE FORM SUBOXONE INTAKE QUESTIONNAIRE ONLY COMPLETE IF APPLICABLE SUBOXONE OR BUPRENORPHINE CONSENT FOR TREATMENT & RELEASE OF INFORMATION ONLY COMPLETE IF APPLICABLE

3. MEDICAL QUESTIONNAIRE ALL MUST COMPLETE

PATIENT MEDICAL QUESTIONNAIRE

NAME *

PLEASE INCLUDE ANY MIDDLE NAME OR INITIAL

DATE OF BIRTH: *

AGE *

PLEASE ENTER AGE IN YEARS

PHONE NUMBER: *

HEIGHT *

FEET, INCHES OR CM

WEIGHT *

POUNDS OR KILOGRAMS

OCCUPATION *

IF DISABLED, PLEASE LIST PRIOR OCCUPATION

EMPLOYER *

PLEASE ALSO INCLUDE TOWN, STATE

GENERAL PAST MEDICAL HISTORY

Have you ever had hepatitis? *

YES

Do you have bleeding tendencies? *

YES

Are you under treatment for high blood pressure? *

YES

Do you drink more than 2 alcoholic beverages (or beer/wine) per day? *

YES

Have you been told by a physician or specialist that you have an alcohol dependency? *

YES

Have you ever been treated for alcoholism ? *

YES

Have you been treated for any type of drug dependency? *

YES

Have you ever been jaundiced (yellow skin-eyes) *

YES

Do you have diabetes? *

YES

Have you had asthma? *

YES

Have you had any other difficulties with breathing? *

YES

Do you have a chronic cough? *

YES

Have you ever had angina or pain in your chest? *

YES

Do you have a history of rheumatoid arthritis? *

YES

Do you have a history of osteoarthritis? *

YES

Have you had epilepsy, seizures or fainting spells? *

YES

Have you ever had a stroke? *

YES

Have you taken any cortisone or steroids in the past 6 months? *

YES

If you are female, could you be pregnant? *

YES

N/A

Have you ever been under the care of a psychiatrist? *

YES

Are you currently under the care of a Psychiatrist? *

YES

List all hospitalizations that were non-surgery or obstetrically related *

MEDICATIONS

DO YOU TAKE ASPIRIN? *

YES

DO YOU TAKE MOTRIN, NAPROSYN OR SIMILAR *

YES

DO YOU TAKE NARCOTIC MEDICATIONS? *

YES

IF SO LIST BELOW

NARCOTIC MEDICATIONS YOU ARE TAKING: *

Narcotics only. Enter "n/a" if not applicable.

Are you taking any Prescription Medications? *

YES

List all (other) medications that you are currently taking *

Enter "n/a" or "none" if not applicable

Over-the-counter medications, vitamins, herbal products and dietary supplements: *

Enter "n/a" or "none" if not applicable

ALLERGIES

Are you allergic to penicillin? *

YES

Are you allergic to latex products? *

YES

Are you allergic to x-ray dye? *

YES

Are you allergic to Sulfa drugs? *

YES

Are you allergic to aspirin? *

YES

Do you have seasonal allergies? *

YES

Do you have any allergic or adverse reaction to food? *

YES

Do you have any allergic or adverse reaction to any drugs or other products? *

YES

Please list any additional allergies or adverse reactions you have, or any additional comments: *

or enter "none"

SURGICAL HISTORY

Please select any surgeries you have had and list dates.

Appendectomy

Hernia

Tonsillectomy

Hysterectomy

Prostate

Heart Bypass

Cataract

Gall Bladder

C-Section

D&C

Back

Neck

Other surgery

Do you have any chipped or loose teeth, dentures, caps, bridgework, braces, etc? *

YES

Are you unusually nervous about surgery or injections? *

YES

Have you ever had a problem with anesthesia? *

YES

COMMENTS:

List any other surgeries with dates:

FAMILY HISTORY

Do you have a family history of Spinal, RSD, Neurological or Other Medical Problems? *

YES

Do you have an immediate family history of alcoholism or drug dependency? *

YES

If yes, please specify:

SMOKING HISTORY

Do you smoke currently, formerly, or never? *

CURRENT

FORMER

NEVER

How many packs per day average?

Enter "0" or "n/a" if not applicable.

At what age did you start smoking?

"n/a" if not applicable.

If you quit, at what age did you quit?

Do you have Smoker's Cough?

Additional comments:

IF YOU FEEL THAT THE DOCTOR SHOULD KNOW ANYTHING ELSE OF IMPORTANCE THAT HAS NOT BEEN PREVIOUSLY MENTIONED

By checking "yes" below, I acknowledge answering the above questions to the best of my ability. *

YES

WARNING: YOU MUST CLICK "SUBMIT FORM" AND SEE A MESSAGE IN GREEN STATING "SUCCESSFULLY SUBMITTED" BEFORE GOING TO THE NEXT FORM OR THE ENTIRE FORM WILL BE LOST

HOW MANY FLIGHTS STAIRS CAN YOU CLIMB? *

TWO OR MORE

ONE

NONE

HOW FAR CAN YOU WALK WITHOUT GETTING SHORT OF BREATH? *

400 FEET or MORE

200 to 400 FEET

LESS THAN 200 FEET

I CANNOT WALK WITH ASSISTANCE OR WHEELCHAIR

* Required field