Pain Management Institute Patient Forms

Patient Name*

First NameMiddle NameLast Name

Date of Birth*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone*

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Patient E-Mail*

Pharmacy Name*

Pharmacy Phone Number*

Area CodePhone Number

Emergency Contact*

Relationship to Patient*

Emergency Contact Phone Number*

Area CodePhone Number

Primary Care Doctor:*

Referring Doctor:*

Primary insurance company

Policy#

Group#

Insurance address:

Name of Insured:

Relation to insured:

Name of responsible party:

If other than self,please provide address:

Responsible party phone number:

Company:

Policy#:

Group:

Address:

Relation to Insured:

Name of responsible party:

If other then self, please provide address:

Phone:

Allergies and reactions*

Medications taken: include medicine, dose, and frequency*

(Including narcotic/controlled medications & pain meds)

Are you currently

Are you on disability?

YesNo

Occupation:

Employer Name:

Employer Address:

Work phone:

Previous Surgeries (include dates-estimate)*

Do you have any past medical history or problems (i.e.. illness, trauma, emotional stress, addictions, drug abuse, or anything else that will help us clearly understand your health condition)?*

Smoking status:*

CurrentFormerNever

If you smoke cigarettes (or other substances), how many do you smoke per day?

How often do you drink alcohol?*

How much at at time?

Other drug use:

Marital status:

Mother:

LivingDeceased

Cause of death:

Father:

LivingDeceased

Cause of death:

With whom do you live:

Is the visit today:*

Workmans CompMotor vehicle claimNeither

Workmans Comp or Motor Vehicle claim case manager:

Phone:

Are there legal/occupational issues pending in regard to your pain condition?

YesNo

Medical History: check all that apply

	Myself
Pregnancy
Hearth Attack
Angina/Chest
Irregular Heartbeat
Heart Murmur
High blood pressure
Fainting episodes
Congestive heart failure
Shortness of breath/Lung dx
Emphysema
Asthma
Recent respiratory infection
Seizures/Epilepsy
Stroke
Depression/mental heath issues
Headaches/Migraines
Peripheral Neuropathy
HIV/Aids
Diabetes
Thyroid disease
Hepatitis -(type)
Ulcers,heartburn,GERD
Kidney disease
Glaucoma
Bleeding problems
Liver disease
Hearing problems
Cancer-(type)
Joint disease/Athritis
Bladder problems
Visual problems
Bowel problems
Dermatological conditions

What does your pain feel like:*

Where is your pain?*

Does your pain go anywhere else?

YesNoSometimes

If yes, where?

Did major life changes occur prior to onset?

The pain is getting:

How did it start?

When did it start?

Date

Did it start:

GraduallySuddenlyNot sure

What makes the pain worse?*

What makes the pain better?*

What time of day is your pain worse?*

On a scale of 1-10, how bad is your pain at the best?*

On a scale of 1-10, how bad is your pain at the worst?*

What time of day is your pain least severe?*

Which statement best describes your pain?*

Always present, always the same intensityAlways present, intensity variesUsually present, but has pain free periods of 1+ hoursOften present, but has pain free periods of 1+ hoursOften present, but is pain free most of the dayOccasionally present, has pain once to several times per day, lasting a few minutes to an hourOccasionally present for brief periods of timeRarely present has pain occasionally during the week

Does pain interrupt your sleep?*

YesNo

If yes, how many times:*

What treatments have you tried for your pain?*

Investigations/Diagnostic studies: Tests done in the past year to evaluate your pain:*

Patient Agreement and Consent
Appointments: A scheduled appointment is a commitment of time between you and our practice and we have reserved that time just for you. If you are unable to keep a scheduled appointment, please cancel or reschedule your appointment at least 24 hours in advance to avoid a $35 service charge and help us meet the needs of other patients.

Payment methods: Payment for services is due at each office visit. If you are unprepared for this, please see the receptionist immediately. Your insurance policy and plan is a contractual agreement between you and your insurance carrier. Each patient is responsible for payment for medical care, regardless of the status of your claim. Because this practice accepts Medicare, those patients on this plan need to make arrangements at the time of their appointment to cover the 20% responsibility as set forth by Medicare guidelines.

Authorization of Treatment: I, the undersigned, hereby authorize providers at The Pain Management Institute to perform necessary treatment in the event of an emergency. Also I am authorizing consent to treatment for any future procedures/treatments after reviewing with the physician. By my signature below, I hereby authorize and direct Nathan Hanflink, D.O. and an assistant of his choice to perform these procedures. My attending physician has (will be) discussed and explained to me the nature and purpose of the procedure. He has (will be) explained to me that there may be possible complications and risks. I understand that no warranty or guarantee has been made as to the results of the procedure. I further understand the procedure may not relieve my pain. Possible risks include infection, bleeding, joint injury, muscle injury, stroke, spinal cord injury, paralysis, epidural abscess, epidural hematoma, spinal puncture, pneumothorax, weakness, numbness, loss of bowel or bladder, loss of sexual function, cardiac arrest, increased pain, death, insomnia, elevation of blood sugar, elevation of blood pressure, weight gain, fluid retention, congestive heart failure, mood changes, skin changes, adrenal suppression, osteoporosis, vertebral compression fractures, and ulcers. I agree that all of my questions have been (will be) answered regarding the risks and benefits of these procedures.

Medical Release: A photocopy of this document shall be sufficient to authorize any person having medical records of any and all treatment, services, or supplies pertaining to me to be released. A true copy of this information may be furnished to The Pain Management Institute, LLC or any insurer providing coverage to me, in connection with any attempt process any claims for benefits made by me are by the assignee herein. A photocopy or fax of this document shall be as binding as an original signature page.

Assignment Of Benefits: I hereby authorize my insurance carrier to provide medical benefit payments to The Pain Management Institute, LLC for medical services rendered. Payment shall not exceed the charges of those services, payable to and mailed directly to The Pain Management Institute, LLC. Furthermore, I hereby a irrevocably assign to The Pain Management Institute, LLC the rights and benefits under any policy of insurance, identity agreement, or any other collateral source as defined in Florida Statutes for any service and/or charges provided by this practice.

Acknowledgment of receipt of notice of "Privacy Practices."

Narcotic Agreement:
This is an agreement between myself and Dr. Hanflink of The Pain Management Institute, LLC regarding the diagnosis for which you are being treated and for which narcotic medications have been/or may be prescribed (specifically related to opiate-based narcotics).
Alternative treatments are available for discussion at the doctors’ discretion or at a patients’ request.
The goal of my therapy is to reduce my pain to a level that is tolerable and will allow me to improve my ability to perform daily activities. I understand that daily use of a narcotic increases certain risks, which include but are not limited to:

-Addiction

-Allergic reactions, overdose, and/or fatal complications

-Breathing problems

-Drowsiness, dizziness and/or confusion

-Impaired judgment and inability to operate machines or drive motor vehicles

-Nausea, vomiting and/or constipation

Development of tolerance

I agree to the following:

1. I will be/have been evaluated for a diagnosis of the physical condition causing my pain.
2. I will be/have been informed of what those symptom generators are or appear to be.
3. I have asked or will ask questions of the doctor to clarify why I hurt as I do.
4. I understand that physical factors, my knowledge of what is wrong, and psychological factors all influence my pain or pain perception.
5. I have tried and will continue to try to use non-medication means of pain control
6. Authorize access to my medication history.
7. I understand some medications used for pain control may be addictive and if stopped may cause a temporary withdrawal reaction, even in people without prior drug problems.
8. I have been truthful and complete in my descriptions to the doctor about any previous problem I have had (if any) with alcohol and mood altering drugs as well as medication.
9. I understand that some pain medicines will cause side effects including but not limited to: sedation, inattentiveness, drowsiness, poor coordination, depression, anxiety, and nausea or other reactions. These symptoms may make it more dangerous for me to drive or operate machinery or other jobs. My first times taking new medication or a new combination of a higher dose are/will be under safe circumstances.
10. I will take this medication only as prescribed and I will not change the amount or frequency without authorization from my physician. Unauthorized changes may result in running out of medication early and early refills will not be allowed. Dr. Hanflink will write a 30 day prescription and will tell you to return in 28-31 days to re-new the prescription. This does not mean to adjust your doctors directions. To avoid being discharged from the clinic you must take "As Directed".
11. I understand that due to the high potential for abuse of these medications, the following rules apply: I WILL NOT BE ALLOWED TO OBTAIN EARLY REFILLS OR RECEIVE REPLACEMENT OF LOST OR STOLEN MEDICATION. Refills will only be provided during regular office hours.
12. I acknowledge instructions to use the least potent medicine that will reduce pain and allow me to function at a more normal level for me.
13. I know that if I have a prior history of drug abuse or chemical and/or alcohol dependency that I am at a greater risk of having that problem re-developed if I use narcotics or sedatives.
14. If I am a woman, I note that many pain medicines are not known to be safe for use during pregnancy or nursing of a baby, and I take appropriate precautions in this regard.
15. I know that my medical condition/injury may be permanent and that long-term treatment may result in actual dependence on the medications in order to function adequately, I am willing to accept those risks if that means I can possibly get along better in some way(s).
16. I will obtain ALL of my pain management prescriptions through Dr. Hanflink and will fill ALL of my prescriptions at the same pharmacy used for primary care physician prescriptions
17. In an acute situation, another provider may prescribe medications for me. If this occurs, I will notify my primary care physician as soon as possible.
18. I will submit to random urine or blood tests if requested by my physician or nurse practitioner to assess my compliance.
19. I agree to see Dr. Hanflink for ongoing case management and will keep regularly scheduled appointments as long as I am taking this narcotic medication.
20. If I do not follow these guidelines, I understand that my treatment may be terminated.
I have discussed the risks, benefits, and alternatives to narcotic treatment with my provider. I have had an opportunity to ask questions and receive answers to those questions to my satisfaction.

First Name Last Name
Date: Date

Patient Signiture*

By signing you agree to the conditions stated above

Patient Information

Primary Insurance

Secondary Insurance

Employment Information

Social History

Pain Assessment