NEW PATIENT FORM: PAIN

  • NEW PATIENT FORM: PAIN

  • Hello and welcome to Bermuda Pain Relief Center. We ask that you help us by providing as much information as you can regarding your current condition and ongoing treatment as well as any prior diagnostic tests, treatments and medical records that you may have had. This questionnaire is designed to step you through all areas of your past and present medical care. Please complete as much of this form as you are able to prior to your first visit, so that we can use this information at the time of your first visit to get a complete picture of you and your overall condition. Please do not hesitate to ask any of our staff or physicians for assistance if you have any questions or concerns. We look forward to meeting you.

  • Date of birth*
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  • Have you previosly been a patient a the Bermuda Pain Relief Center*
  • Have any of your details changed (Home address, health insurance provider, employer, GP)
  • Type of health insurance plan*

  • Patient information

  • I, hereby grant permission to Bermuda Pain Relief Center to release my health information, encompassing, but not restricted to, office notes, laboratory results, and radiology findings. Additionally, I consent to the utilization of my image as an integral component of my medical record by the Bermuda Pain Relief Center.

    Your medical records will only be shared with your General Practitioner, your referring Physician and any other health care provider of your preference.

    Please advise us if you would prefer us to limit the sharing of your medical records.

    Please advise us if you do not wish to receive periodic emails regarding services and procedures offered at the Bermuda Pain Relief Center.

    FINANCIAL POLICY AND AGREEMENT

    Bermuda Pain Relief Center is committed to providing you with the best in Pain Management Services. Our fees are based on current specialist pricing.

    INSURANCE PAYMENTS 

    We encourage you to know your Schedule of Benefits based on your insurance policy. Your co-payment is due at the time of your visit and you are liable for any charges incurred as a result of services rendered, regardless of how your insurance provider pays for your claim.

    CANCELLATION POLICY 

    We ask that you make your appointments carefully to ensure that you are able to keep them. After three no shows you will not be able to reschedule with Bermuda Pain Relief center. For cancellations with less than 24 hours notice you will be charged 50% of the consultation fee. If you arrive past your scheduled appointment time, you may be asked to reschedule.

  • I,   *   *   certify that I have read and understand the above information. I authorize and request my insurance company to pay my claim directly to the Bermuda Pain Relief Center. I understand that my health insurance provider may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf.
    By signing, you acknowledge the physician may use an AI-assisted scribe to transcribe and summarize dictated clinical notes; the physician reviews and approves all records. Use is subject to applicable privacy laws and you may decline AI-assisted documentation by notifying staff.

  • Date*
     / /
  • I would like to recieve periodic emails regarding services and procedures offered at the Bermuda Pain Relief Center

  • DESCRIBE YOUR PAIN SYMPTOMS

  • Did your pain begin with an injury:*
  • What does your pain feel like? (check all that apply)*
  • What is the pattern of your pain?*
  • What makes you pain better? (check all that apply)*
  • What makes the pain worse? (Check all that apply)*
  • Does your pain interfere with any of the following? (check all that apply)*
  • How does the pain make you feel? (Check all that apply)
  • Have you had any treatments for you pain? (Check all that apply)*
  • Have you had any tests that relate to the current pain? (Check all that apply) Please bring ALL reports to your visit.

  • MEDICATIONS AND ALLERGIES

  • Current pain medications:

  • Previous pain medications:

  • MEDICAL HISTORY

  • Have you ever had any of the following conditions? (Check all that apply)*

  • SOCIAL HISTORY

  • Do you smoke?
  • Do you drink alcohol?
  • Do you use recreational drugs?
  • Do you exercise regularly?
  • Are you currently working?
  • What is the highest level of education you have completed? (Please check one)
  • What is you marital status? (Please check one)

  • PSYCHOSOCIAL HISTORY

  • Have you ever been treated for emotional/behavioural disorders?
  • Have you ever been treated for depression?
  • Have you ever attempted suicide?
  • Do you currently have suicidal thoughts?
  • Is there any chance you could be pregnant?
  • REVIEW OF SYMPTOMS: (Check all that apply)*
  • Are you right handed or left handed?
  • Date*
     / /
  • Should be Empty: