Sussex Pain Relief Center - New Patient Questionnaire

New Patient Questionnaire

Georgetown: 18229 DuPont Blvd || Rehoboth Beach: 18947 John J Williams Hwy, Suite 305 || Phone: 302.514.7246 || Fax: 302.253.8028 || Email: newpatient@sussexpainrelief.com
The following questionnaire is a very important tool that is used to assess your pain condition. You are unique to us as a patient. In order to provide a treatment plan specific to you, we need to understand who you are, your medical history, and what you’ve been through.

Please read and fill out the entire form. If you exit the form before completing, the information will NOT be saved. We recommend gathering the necessary information before you begin. Failure to complete or sign this form will delay your appointment.

Please bring these items to the office for your initial consultation:
- Insurance and prescription cards
- Photo ID
- Imaging reports and films / disks related to your pain
- Medication List / Prescription Bottles

DEMOGRAPHICS
Name *

First Name Middle Name Last Name Suffix
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Select your Gender *
Select the race you identify with
Enter your Social Security Number *
Enter your Date of Birth *

Month Day Year
Date
How can we contact you? *

Primary Work Cell
Primary Phone *
Please enter a valid phone number.
Work Phone *
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.

EMERGENCY CONTACT
Enter their name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Relation to them *

INSURANCE INFORMATION
Select your Primary Insurance *
Enter the name of your Primary Insurance
Enter your ID #
Enter your Group #
Please take a photo of the front of your insurance card
Please take a photo of the back of your insurance card
Do you have Secondary Insurance? *

Yes No
Select your Secondary Insurance *
Enter the name of your Secondary Insurance
Enter your ID #
Enter your Group #
Take a photo of the front of your insurance card
Take a photo of the back of your insurance card
Do you have a Prescription Card? *

Yes No
Enter your ID #
Enter your BIN#
Enter your PCN#
Enter your Rx Group#
Select your Rx Pharmacy
Take a photo of the front of your Prescription Card
Take a photo of the back of your Prescription Card

CIRCLE OF CARE
Enter the name of your Referring Provider *
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Do you have a Primary Care Physician? *

Yes No
Enter the name of your Primary Care Provider *
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.

CONSENT FOR TREATMENT AND FINANCIAL AGREEMENT
I hereby request treatment to be performed by physicians or providers of Sussex Pain Relief Center and/or assistants.

Such treatments to include: injections, ultrasound, diagnostic procedures, and such other office procedure as they deem necessary.

I accept full responsibility for any charges incurred for services rendered to me.
Patient Signature *

Clear
Date *

Month Day Year
Date

ORTHOPEDIC SURGEON
Have you seen a Orthopedic Surgeon? *

Yes No
Enter the name of the Orthopedic Surgeon and their Facility *

Name of Surgeon Name of Facility
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028
Patient Name

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I authorize release of my medical record(s) from
Physician/Facility

Name of Physcian Name of Facility
Address of Physician/Facility

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

Address: 18229 Dupont Blvd, Georgetown, DE 19947
Fax: (302) 253-8028

Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

CONSENT
I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services.

NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.
Patient Signature *

Clear
Date *

Month Day Year
Date

NEUROLOGIST
Have you seen a Neurologist? *

Yes No
Enter the name of the Neurologist and their Facility *

Name of Neurologist Name of Facility
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028
Patient Name

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I authorize release of my medical record(s) from
Physician/Facility

Name of Physcian Name of Facility
Address of Physician/Facility

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

Address: 18229 Dupont Blvd, Georgetown, DE 19947
Fax: (302) 253-8028

Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

CONSENT
I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services.

NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.
Patient Signature *

Clear
Date *

Month Day Year
Date

RHEUMATOLOGIST
Have you seen a Rheumatologist? *

Yes No
Enter the name of the Rheumatologist and their Facility *

Name of Rheumatologist Name of Facility
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028
Patient Name

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I authorize release of my medical record(s) from
Physician/Facility

Name of Physcian Name of Facility
Address of Physician/Facility

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

Address: 18229 Dupont Blvd, Georgetown, DE 19947
Fax: (302) 253-8028

Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

CONSENT
I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services.

NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.
Patient Signature *

Clear
Date *

Month Day Year
Date

CHIROPRACTOR
Have you seen a Chiropractor? *

Yes No
Enter the name of the Chiropractor and their Facility *

Name of Chiropractor Name of Facility
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028
Patient Name

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I authorize release of my medical record(s) from
Physician/Facility

Name of Physcian Name of Facility
Address of Physician/Facility

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

Address: 18229 Dupont Blvd, Georgetown, DE 19947
Fax: (302) 253-8028

Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

CONSENT
I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services.

NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.
Patient Signature *

Clear
Date *

Month Day Year
Date

Pain Management
Have you ever been seen at another Pain Management provider? *

Yes No
Enter the name of the Pain Physician and their Facility *

Name of Physician Name of Facility
When were you last seen by them? [An approximate date is acceptable]

Month Day Year
Date
Why did you leave them?
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028
Patient Name

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I authorize release of my medical record(s) from
Physician/Facility

Name of Physcian Name of Facility
Address of Physician/Facility

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

Address: 18229 Dupont Blvd, Georgetown, DE 19947
Fax: (302) 253-8028

Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

CONSENT
I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services.

NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.
Patient Signature *

Clear
Date *

Month Day Year
Date

PAIN HISTORY

Primary Pain
Question: What is your Primary Pain?
Where is your Primary Pain? *
Specify where your primary pain is including which side of the body, etc
You can leave a voice recording describing your primary pain if you prefer
When did the pain first start? *

Month Day Year
Date
Was this Work, Auto, and/or Trauma related? *
Was the timing of the pain sudden/gradual/spontaneous? *
Where does your Primary Pain radiate to? *

PAST PAIN TREATMENT

Describe what you have tried in the past for your pain. Let us know what helped.
Which of these NSAIDs (anti inflammatory medication) have you tried? *
What other NSAIDs have you tried?
Which of these Pain Medications have you tried? *
What other Pain Medications have you tried?
Select therapies you've tried *
Describe any other treatment you have tried in the past for your pain

Physical Therapy
When did you try Physical Therapy? *
Did Physical Therapy help? *
Chiropractic Therapy
When did you try Chiropractic Therapy? *
Did Chiropractic Therapy help? *
Injections
What type of Injections did you try? *
When were the Injections? *
Did the Injections help? *

MEDICATIONS
Do you take medication currently? *

Yes No Other
Explain what you mean by other *
List your current medications [Click the + to add text lines] *

PAST MEDICAL & SOCIAL HISTORY
Select the medical condition(s) you have been diagnosed with *
Have you ever been diagnosed with or treated for any of the following health problems? *
Detail your other health problems *
What type of cancer do or did you have? *
What year(s) did you have congestive heart failure? *
What year(s) did you have a heart attack? *
What type of neuropathy do you have? *
Describe your paralysis *
What year did you have a stomach or duodenal ulcer? *

SURGICAL & HOSPITAL HISTORY
Have you previously had surgery? *

Yes and I have a list of surgeries I can upload to the form Yes, but I want to manually enter each one No
Upload the list of surgeries *

Cancel of
List past surgeries and the date(s) of the surgery [Click the + to add text lines] *
Have you been to the hospital in the last 30 days? *

Yes No
Describe when, where and why *

FAMILY HISTORY
List health issues that your parents have or had [Click the + to add text lines]

Does anyone in your immediate family (mother, father, sisters, brothers, grandparents) have any of the following: *

	Yes	No
Family history of Addiction:
Family history of Cancer:
Family history of Alcoholism:
Family history of Chronic Pain:

FUNCTIONAL HISTORY
Select any of the following that you are unable to do: *
What has pain limited your ability to do?

SOCIAL HISTORY
Select your current marital status *
How many children do you have? *
Select whom you are living with *
Select the option most applicable to your alcohol use *
Select the option most applicable to your illicit drug use *
Select the option most applicable to your history of sexual abuse *
Select the option most applicable to your history of tobacco use *

WELCOME LETTER & PRACTICE POLICIES
Dear Patient,

The purpose of this letter is to tell you about our general practice policies and position on using controlled substances, such as Opioids (narcotics), to treat pain. We give this letter to all our new patients. If you have any further questions after reading this letter, remember to discuss them with your doctor.

We will explore all medical treatment options within the scope of our medical practice to help you restore function and lead an active, healthy life, using a variety of treatments to accomplish our goals including but not limited to physical therapy, procedures, heat and/or cold therapy, a home exercise program, non-controlled medications and, in some cases, controlled medications. We require all our patients to have a primary care physician and we expect you to help us obtain your medical records from your primary care doctor and any other doctor who has treated you using controlled medications. The faster we receive records, the faster you’ll be seen.

If your healthcare practitioner decides to prescribe controlled medications to you as part of your overall treatment plan, he/she must and will follow federal and state laws and regulations governing controlled substance prescribing.
Here are just a few of the things we may ask you to provide for us in connection with our patient selection and treatment process:

1) Get information from your doctors about your medical history and your past pain treatments, including a list of all medications you take to treat your pain;

2) Ask whether you or your family has had any problems with alcohol, illegal drugs, legal drugs, or tobacco; and

3) Ask you to provide a urine sample for testing as part of the initial patient selection process. If we accept you into our pain management and rehabilitation program, we may ask you to submit additional urine samples as part of your ongoing treatment program. All urine samples are requested at the discretion of
your healthcare practitioner and you will be asked to cooperate with us or we have the discretion to not treat you.

We will monitor your medical condition and supervise your use of medication using various tools in addition to urine drug testing, including medication counts, family conferences, psychological consultations, etc. These tools are not meant to be offensive and are used in conjunction with professional and state/federal guidelines.

Furthermore, third-parties such as insurance companies, require that we perform these tests to obtain prior authorization for medications and procedures. We want you to know that we are committed to treating you and doing what is medically acceptable and appropriate for you to help you control your pain. We look forward to serving you and empowering you to take control of your pain.

Sincerely,
Dr. Manonmani Antony
Patient Signature *

Clear
Date *

Month Day Year
Date

PATIENT CONSENT & ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

FINANCIAL POLICY
Should be Empty:

	Never	Seldom	Sometimes	Often	Very Often
How often do you have mood swings?
How often have you felt a need for higher doses of medication to treat your pain?
How often have you felt impatient with your doctors?
How often have you felt that things are just too overwhelming that you can't handle them?
How often is there tension in the home?
How often have you counted pain pills to see how many are remaining?
How often have you been concerned that people will judge you for taking pain medication?
How often do you feel bored?
How often have you taken more pain medication than you were supposed to?
How often have you worried about being left alone?
How often have you felt a craving for medication?
How often have others expressed concern over your use of medication?
How often have any of your close friends had a problem with alcohol or drugs?
How often have others told you that you had a bad temper?
How often have you felt consumed by the need to get pain medication?
How often have you run out of pain medication early?
How often have others kept you from getting what you deserve?
How often, in your lifetime, have you had legal problems or been arrested?
How often have you attended an AA or NA meeting?
How often have you been in an argument that was so out of control that someone got hurt?
How often have you been sexually abused?
How often have others suggested that you have a drug or alcohol problem?
How often have you had to borrow pain medications from your family or friends?
How often have you been treated for an alcohol or drug problem?

New Patient Questionnaire

DEMOGRAPHICS

EMERGENCY CONTACT

INSURANCE INFORMATION

CIRCLE OF CARE

CONSENT FOR TREATMENT AND FINANCIAL AGREEMENT

ORTHOPEDIC SURGEON

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

NEUROLOGIST

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

RHEUMATOLOGIST

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

CHIROPRACTOR

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Pain Management

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

PAIN HISTORY

Rate Your Primary Pain

PAIN HISTORY

PAST PAIN TREATMENT

Physical Therapy

Chiropractic Therapy

Injections

MEDICATIONS

PAST MEDICAL & SOCIAL HISTORY

ALLERGIES

SURGICAL & HOSPITAL HISTORY

FAMILY HISTORY

FUNCTIONAL HISTORY

SOCIAL HISTORY

WELCOME LETTER & PRACTICE POLICIES

SOAPP-R

OSWESTRY

Global Pain Scale

PATIENT CONSENT & ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES

FINANCIAL POLICY