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

4. PAIN ASSESSMENT FORM ONLY COMPLETE IF APPLICABLE

PATIENT NAME *

Please enter your name

DATE OF BIRTH *

Please enter date of birth

TELEPHONE *

DOMINANT HAND *

RIGHT HANDED

LEFT HANDED

AMBIDEXTROUS

Are you off from work because of your current problem *

YES

Since what date have you been out of work, if applicable.

To what is your current problem related? *

If your pain is a result of a work or auto injury please describe the injury thoroughly.

Date of injury or when condition began. *

Please list a brief history of your current symptoms. *

Please describe any relevant symptoms of this episode. *

Currently on a scale of 1 to 10, pain (1 is very little pain and 10 is the worst pain imaginable) *

At its best.

At its worst.

Last week on average:

Date of last episode? *

When was the last time you had pain?

Magill Pain Questions *

Check all that apply

Are your symptoms: *

improving

worsening

unchanging

Are you experiencing numbness? *

Yes

Are you experiencing Pins and Needles? *

Yes

Symptoms at onset affected which area(s)?

Constant symptoms affect which area(s)?

What hurts all the time, if applicable and give a brief description.

Intermittent symptoms effect what area(s)?

What hurts only sometimes, if applicable and give a brief description.

Are you having any bowel problems? *

Yes

Please indicate the problem, if applicable.

i.e. diarrhea, constipation, incontinence

Do you have any bladder problems? *

Yes

Please indicate the problem, if applicable.

i.e. urinary incontinence, urinary frequency

Do you have? ( check all that apply) *

Do you have disturbed sleep? *

Yes

If other please clarify.

Are you depressed from the pain? *

Yes

Have you ever had thoughts about, or ever attempted suicide? *

Yes

Do you experience headaches or facial pain? *

Yes

How would you rate your headaches? *

n/a

Mild

Moderate

Severe

Do you have migraines? *

Yes

Do you have sinus type pain? *

Yes

Ringing in the ears? *

Yes

Pain in teeth or jaw? *

Yes

Pain in or Near Eyes? *

Yes

Pain in back of head? *

Yes

HAVE YOU HAD? (Check all applicable) *

Please explain and list the doctor's or hosptial's name, town and phone number below.

DATE(S) LOCATION(S) PHYSICIAN'S FACILITY NAME

diagnostic tests check all that apply *

X-RAYS

ULTRASOUND

MRIS

CAT SCAN

EMG NERVE CONDUCTION

DISCOGRAPHY

NO TESTING

Please indicate dates and facility/office of most recent test below.

Dates of Most Recent Test and Where

Do you undergo psychotherapy?

If yes, please list treating physician or therapist in Comments below

COMMENTS

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

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

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