Pain Management Intake Form

Pain Management Intake Form

Step 1 of 21

Patient Registration

Date

MM slash DD slash YYYY

Patient Name:

Date of Birth:

MM slash DD slash YYYY

Marital Status:

Married

Single

Divorced

Widowed

Home Address:

City, State, Zip:

Home Phone:

Cell Phone:

Email Address:

Referring Physician:

Phone/Fax:

Are you involved in a litigated case?

Yes

Private Insurance

Primary Insurance Information:

Secondary Insurance Information:

Primary Insurance:

Name of Insured:

Secondary Insurance:

Name of Insured:

Claims Address:

Insured Date of Birth:

MM slash DD slash YYYY

Claims Address:

Insured Date of Birth:

MM slash DD slash YYYY

Policy #:

HIPAA Compliance Patient Consent Form

Doctor:

Practice:

Patient Name:

Patient Phone Number:

Patient Email:

Patient Address:

Street Address Address Line 2 City State Zip Code

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.

May we call your phone number and leave a voicemail regarding appointments, medication, and/or other medical questions?

Yes

May we discuss your medical condition with any member of your family?

Yes

If yes, please name the members allowed:

Click + to add additional family members. Limited to 4 entries

This consent was signed by:

Print Name Please

Signature:

Date

MM slash DD slash YYYY

Patient Financial Responsibility Form/Office Fees

Patient Name:

Date of Birth:

MM slash DD slash YYYY

Edinger Pain Management is out of network with all insurance carriers except Medicare. However, due to the decreased reimbursement rate of 2023, we can no longer accept and send claims to Medicare. Therefore, in order to see Dr. Edinger, you will have to pay out of pocket for her services, even if you are a member of Medicare.

At the time of service, all Medicare patients will have to sign our Advance Beneficiary Notice of Non-Coverage (ABN) form to continue care. All payments must be made at the time of service, for both Medicare and Non-Medicare patients.

New Consultation: $800 per hour (Charged based on time)

Follow Up Visits: $600 per hour (Charged based on time)
Note: Every follow up appointment will be automatically booked for 45 minutes, however, depending on the complexity of your case, your appointment can run shorter or longer than 45 minutes, and you will be charged based on the total time spent.

Other Treatment and Services: The cost is dependent on the type of service. You will need to call the front office for specific pricing for the type of service.

*Once you are an established patient and you need to speak to Dr. Edinger during/after business hours for an emergency, everything will be documented accordingly as a visit and you will be charged after the 15 minute mark. At that point, you will be charged based on the amount of time spent during the call at the $600 hourly rate.*

Cancelation & No Show Policies

We understand there are times when you must miss an appointment, either for emergencies or obligations for work or family. However, when the office is not notified of your cancellation, you may be preventing another patient from getting much needed treatment. The situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to our full appointment book. Therefore, if you must cancel your scheduled appointment, please call the office 24 hours in advance.

If patient fails to show for their scheduled appointment, or did not notify the office within 24 hours, they shall be subjected to a “No Show” fee. In the event of an actual emergency and prior notice could not be given, consideration may be given and a one-time exception may be granted.

New Consultation Cancelation Fee: $400.00
Follow Up Cancelation Fee (less than 24 hours): $150.00
Follow Up Cancelation Fee (Day of/time of service): $300.00
Follow Up No Show Fee: $300.00

If you understand and agree to these charges, please initial your first and last name below and sign your full name.

Initial:

I want to receive services from Edinger Pain Management. I accept and agree to pay for all services rendered as stated above. Services include: Consultations, evaluations, procedures, and other forms of treatment.

Initial:

I understand that if there is any debt to my account and I am unable to pay for any reason, the debt shall transfer to my legal guardian and/or spouse. They will then be responsible for any balance due on my account and must pay it in full, otherwise it will be sent to collections after 90 days.

Patient Full Name:

Legal Guardian/Spouse Full Name:

Patient Signature:

Legal Guardian/Spouse Signature:

Date

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

*NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our office. If a claim is submitted to your insurance, your health information on this form may be shared with them.

Name:

Date of Birth

MM slash DD slash YYYY

Date

MM slash DD slash YYYY

PRESENT STATUS OF CURRENT PAIN PROBLEM

Diagram: Front

Choose the approximate location(s) of where you are experiencing pain

Right:

2. Shoulder

5. Bicep

8. Forearm

11. Hip

13. Wrist/Hand

15. Thigh Region

17. Knee

19. Shin

21. Foot/Ankle

Left:

3. Shoulder

6. Bicep

9. Forearm

12. Hip

14. Wrist/Hand

16. Thigh Region

18. Knee

20. Shin

22. Foot/Ankle

Center:

1. Forehead (Head/Face Region)

4. Chest

7. Abdomen Region

10. Pelvic/Groin Region

Diagram: Back

Choose the approximate location(s) of where you are experiencing pain

Right:

3. Shoulder

6. Shoulder Blade Region

9. Triceps

12. Forearm

15. Gluteus

17. Wrist

19. Upper Hamstrings

21. Hamstrings

23. Knee

25. Calf Muscle

27. Achilles/Heel

Left:

2. Shoulder

5. Shoulder Blade Region

8. Triceps

11. Forearm

14. Gluteus

16. Wrist

18. Upper Hamstrings

20. Hamstrings

22. Knee

24. Calf Muscle

26. Achilles/Heel

Center:

1. Neck

4. Upper Back

7. Mid Back

10. Lower Back

13. Tailbone

HISTORY OF PAIN PROBLEM

1. Were you referred by a physician to this practice?

1. yes, no, na

Yes

Please provide the name of the physician:

Physician's Phone Number

2. What is your primary complaint?

2. Primary Complaint

3. When did your symptoms start?

Approximate Symptom Start Date:

MM slash DD slash YYYY

4. What started your symptoms?

(check all that apply)

question 4 checkboxes

Unknown

Motor Vehicle Accident (Must Specify)

Repetitive Strain Injury (Must Specify)

Surgery (Must Specify)

Stroke

Injury (Must Specify)

Other, specify

Motor Vehicle Accident: Specify

Repetitive Strain Injury: Specify

Surgery: Specify

Injury: Specify

Other: Specify

5. On average, what is your pain level WITH medication?

(0 no pain - 10 being the worst)

question 5 scale

Please enter a number from 0 to 10.

6. On average, what is your pain level WITHOUT medication?

(0 no pain - 10 being the worst)

question 6 scale

Please enter a number from 0 to 10.

7. Is your pain...

question 7 radio

Constant (Continuous)

Intermittent (Occasional)

8. What types of pain are you experiencing?

(Check all that apply)

question 8 checkboxes

Burning

Painful Itching

Shooting

Throbbing

Aching

Crushing

Gnawing

Electrical Shocks

Cramping

Stinging

Stabbing

Squeezing

Sensitivity

Hurts to be lightly touched

9. What makes the pain worse?

(Check all that apply)

question 9 checkbox

Exercise (during)

Exercise (after)

Sitting

Standing

Walking

Bending Forward

Bending Backward

Coughing

Sneezing

Gripping

Carrying Items

Reaching Overhead

Wearing Clothes

Other

Other: Specify

10. What reduces the pain?

(Check all that apply)

10. what reduces pain checkboxes

Lying down

Walking

Chiropractic/Osteopathic manipulation

Ice

Stretching

Sitting

TENS Unit

Psychological therapy

Pain medicine

Muscle relaxant pills

Standing

Physical Therapy

Heat

Massage

Anti-Inflammatory medicine

Other

Other: Specify

11. Review of Systems:

Check the box if you have had any of these symptoms recently.

Constitutional:

Unexpected weight loss

Fever

Fatigue

Sweats

Chills

Head & Neck:

Blurry vision

Ringing in the ears

Hearing loss

Difficulty swallowing

Pulmonary:

Shortness of breath

Wheeze

Cough

Snoring

Cardiac:

Chest pain

Palpitations

Lightheadedness when rising from sitting

Gastro-Intestinal:

Nausea

Vomiting

Abdominal pain

Incontinence of stool

Constipation

Diarrhea

Blood in stool

Feel full after small amounts of food

Genito-Urinary:

Frequent urination

Painful intercourse

Difficulty starting to urinate

Menstrual irregularity

Painful menstruation

Blood in urine

Incontinence

Endocrine:

Kidney stones

Feeling too hot

Cold intolerance

Increased thirst

Hair loss

Hematologic:

Spontaneous bruising

Excessive bleeding

Musculoskeletal:

Joint pain

Joint swelling

Joint redness

Joint stiffness

Joint warmth

Muscle cramps

Muscle weakness

Difficulty walking (require cane/walker)

Neurological:

Headaches

Seizures

Paralysis

Memory Loss

Confusion

Difficulty sleeping

Numbness

Tingling

Skin:

Rash

Itching

Sores

Allergic/Immunologic:

Seasonal allergies

Frequent infections

Psychological:

Depression

Anxiety

Panic attacks

Suicide attempts

Suicidal thoughts

12. Medication Allergies:

Please list all medications you currently have allergies to.

If you have more than 6 medication allergies, please contact us once your form is submitted to include all missing medication allergies.

Please list all medication allergies:

Click the plus (+) to add more medications to the list.

Do you have an allergy to contrast dye?

Yes

If yes, what was the test?

MRI

What type of reactions?

13. Current Medications:

Please list any medications that you are currently taking.

If you are taking more than 9 medications, please contact us once your form is submitted to include all missing medication.

question13 medication list

Medication Name

Medication Dosage

How many times a day or as needed?

Click the plus (+) to add more medications to the list.

14. Current Supplements and Vitamins:

Please list any supplements/vitamins that you are currently taking.

If you are taking more than 9 supplements/vitamins, please contact us once your form is submitted to include all missing supplements/vitamins.

question14 medication list

Supplement/Vitamin Name

Dosage

Frequency Taken

Click the plus (+) to add more supplements/vitamins to the list.

15. If you are not on oral steroids currently, have you taken oral steroids in the last year?

Question15_radio

Yes

If yes, please list the following:

Name of steroid:

Dose:

Duration:

Month Taken:

16. Have you taken Ketamine previously?

question16_radio

Yes

If yes, please explain the route (oral, intravenous, intranasal), dose, frequency of use, prescriber or clinic where it was provided:

17. Past Medications:

Question 17: Part 1 of 2

Please select which medications you have taken in the PAST.

Medication Names:

Gabapentin (Neurontin)

Lorazepam (Ativan)

Pregabalin (Lyrica)

Clonazepam (Klonopin)

Topiramate (Topamax)

Diazepam (Valium)

Carbamazepine (Tegretol)

Alprazolam (Xanax)

Oxcarbmazepine (Trileptal)

Morphine Extended release (MS Contin)

Lamotrigine (Lamictal)

Morphine Immediate Release

Duloxetine (Cymbalta)

Fentanyl Patch (Duragesic)

Venalfaxine (Effexor)

Hydrocodone / APAP (Vicodin)

Amitriptyline (Elavil)

Oxycodone Extended release (Oxycontin)

Nortriptyline (Pamelor)

Oxycodone immediate release (Roxicodone or Percocet)

Carisoprodol (Soma)

Hydromorphone (Dilaudid)

Cyclobenzaprine (Flexeril)

Tramadol (Ultram)

Methocarbamol (Robaxin)

Tapentadol (Nucynta)

Tizanidine (Zanaflex)

Buprenorphine Patch (Butrans)

Baclofen

Buprenorphine / Naltrexone sublingual tablets or films (Suboxone)

Celecoxib (Celebrex)

Buprenorphine Oral films (Belbucca)

Meloxicam (Mobic)

Buprenorphine sublingual tablets (Subutex)

Nabumetone (Relafen)

Lidocaine Patches

Ibuprofen (Advil)

Diclofenac topical (Volteran gel)

Other:

None Apply

17. Past Medications:

Question 17: Part 2 of 2

Specify whether the medication you taken was helpful or not.

No medications selected in previous selection.

Please click "Next" to continue.

Was Gabapentin (Neurontin) Helpful?

Yes

N/A

Was Lorazepam (Ativan) Helpful?

Yes

N/A

Was Pregabalin (Lyrica) Helpful?

Yes

N/A

Was Clonazepam (Klonopin) Helpful?

Yes

N/A

Was Topiramate (Topamax) Helpful?

Yes

N/A

Was Diazepam (Valium) Helpful?

Yes

N/A

Was Carbamazepine (Tegretol) Helpful?

Yes

N/A

Was Alprazolam (Xanax) Helpful?

Yes

N/A

Was Oxcarbmazepine (Trileptal) Helpful?

Yes

N/A

Was Morphine Extended release (MS Contin) Helpful?

Yes

N/A

Was Lamotrigine (Lamictal) Helpful?

Yes

N/A

Was Morphine Immediate Release Helpful?

Yes

N/A

Was Duloxetine (Cymbalta) Helpful?

Yes

N/A

Was Fentanyl Patch (Duragesic) Helpful?

Yes

N/A

Was Venalfaxine (Effexor) Helpful?

Yes

N/A

Was Hydrocodone / APAP (Vicodin) Helpful?

Yes

N/A

Was Amitriptyline (Elavil) Helpful?

Yes

N/A

Was Oxycodone Extended release (Oxycontin) Helpful?

Yes

N/A

Was Nortriptyline (Pamelor) Helpful?

Yes

N/A

Was Oxycodone immediate release (Roxicodone or Percocet) Helpful?

Yes

N/A

Was Carisoprodol (Soma) Helpful?

Yes

N/A

Was Hydromorphone (Dilaudid) Helpful?

Yes

N/A

Was Cyclobenzaprine (Flexeril) Helpful?

Yes

N/A

Was Tramadol (Ultram) Helpful?

Yes

N/A

Was Methocarbamol (Robaxin) Helpful?

Yes

N/A

Was Tapentadol (Nucynta) Helpful?

Yes

N/A

Was Tizanidine (Zanaflex) Helpful?

Yes

N/A

Was Buprenorphine Patch (Butrans) Helpful?

Yes

N/A

Was Baclofen Helpful?

Yes

N/A

Was Buprenorphine/Naltrexone sublingual tablets/films (Suboxone) Helpful?

Yes

N/A

Was Celecoxib (Celebrex) Helpful?

Yes

N/A

Was Buprenorphine Oral films (Belbucca) Helpful?

Yes

N/A

Was Meloxicam (Mobic) Helpful?

Yes

N/A

Was Buprenorphine sublingual tablets (Subutex) Helpful?

Yes

N/A

Was Nabumetone (Relafen) Helpful?

Yes

N/A

Was Lidocaine Patches Helpful?

Yes

N/A

Was Ibuprofen (Advil) Helpful?

Yes

N/A

Was Diclofenac topical (Volteran gel) Helpful?

Yes

N/A

Other: Please Specify

18. Imaging:

Write what body part was imaged and the year it was done.

X-rays:

Yes

State Body Part and Year of Imaging:

CT Scan:

Yes

State Body Part and Year of Imaging:

MRI:

Yes

State Body Part and Year of Imaging:

Myelogram (contrast in the CSF):

Yes

State Body Part and Year of Imaging:

Arthrogram (contrast in a joint):

Yes

State Body Part and Year of Imaging:

19. Previous Testing:

Leave blank if not applicable or you are not sure.

If you’ve had any of these tests, please list where it was done and in what year.

EMG/NCS:

Yes