family first health care pain management: a georgia … · 2017-08-01 · family first healthcare:...

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FAMILY FIRST HEALTH CARE PAIN MANAGEMENT: A GEORGIA LICENSED PAIN CLINIC

New Patient Packet

Family First Healthcare: Pain Management

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Introduction: We welcome you to our Pain Management Clinic dedicated to provide cost

effective timely care for local population. Our physicians are specializing in the treatment

of pain.

Hours of Operation: The FFHC Pain Clinic, Athens

Hours are from 8 AM to 4:30 PM Saturdays.

Initial Visit: Your initial consultation visit takes about 1 hour and is usually an evaluation

only. At your consultation visit, you will need to change into a gown (except for

underclothing), so the physician can examine you. After the physician has completed your

examination, he will give you his commendations, answer questions, and talk about a plan

of care; medication do not going to be prescribed on the first consult. On the second visit

treatment options and pain medication approval will be discussed.

Before you will be seen by our physician.

1. You need to fill out new patient questionnaire

2. Read, understand and sign pain management patient care agreement

3. Do urine drug screen.

4. Opioid Risk Tool questionnaire

5. Sign release of information from previous physicians

6. Sign appointment and No show policy

7. Authorization for collection, use, and release of Personal and Medical Confidential Information 8. Medication Risks Acknowledgement 9. Prescription Monitoring Program: using Georgia PDMP Appointment: If you need to cancel your appointment, 24 hours notice is required. Failure to give us adequate notice will result in a charge of $ 25.00 for “no show”.

This is due at the next appointment.

Contact Information: Lorena Rico,

2005 Prince Ave, Athens GA 30606

Office Phone: (844) 614-0036 Email: [email protected]

mailto:[email protected]


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Pain management patient Initial Visit

Name: Home/ Cell:

Address: Email:

City: State: Zip: Marital Status: Single Married

Divorce Widowed Divorced Widowed

Date of Birth: SS #: Sex: Male Female

Race: American Indian or Alaskan Native Asian Black or African American

Hispanic or Latino Native Hawaiian or Other Pacific Islander White Decline to

Answer Ethnicity: Hispanic or Latino Non Hispanic or Non Latino Decline to Answer

Preferred Language: Preferred Method of Contact:

Employer: Occupation:

Address: Phone:

City: State: Zip:

Referred By: Phone:

Address:

City: State: Zip:

Emergency Contact:

2nd Emergency Contact:

Relationship & Phone:

Relationship & Phone:

Name: /cell: Home: DOB: ____/____/_____

Address:

Email:


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Main Reason for this visit? __________________________________________________________________________________________________________________________________________________________________________________________________________________ My pain stated after…………. when where dscription An Injury After Surgery Auto accident Injury at work After illness I don’t Know Family history Living /Death Age State of Health: for ex. (High blood pressure,

diabetes, stroke, heart attack, etc. or Cause of Death)

Father _________________________________________________________

Mother _________________________________________________________

Brother’s _________________________________________________________

_________________________________________________________

_________________________________________________________

Sister’s _________________________________________________________

_________________________________________________________

_________________________________________________________

3. Do you have a Lawyer regarding this injury? __________ If you answer is yes. Name of the lawyer_____________________________________________

What do you think caused your pain? _____________________________________________________________________________________________________________________________________________________ _


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On the diagram, shade in the areas where you feel pain , Put an O on the are that hurts the most.

Pain scale score: INTENSITY: Mild / Moderate / SEVERE |_____|_____|_____|_____|_____|_____|_____|_____|_____|_____| 0 1 2 3 4 5 6 7 8 9 10 Present Pain: ___ Worst pain gets: ___ Best pain gets: ___ Acceptable level pain____ My pain is……… (Select ONE ANSWER only)

Always present, always the same intensity Always present, intensity varies Usually present—short periods without pain Often present—but have pain-free periods lasting for one to several hours

My pain is……… (Select ONE ANSWER only)

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The type of pain I feel is…………..

I also have associated…………..


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My pain gets worse with………….. Laying down

My pain gets better with……………

My pain is interfering with my………….

-

Because of my pain, I have problems with………….

my sleep

My goals with pain control are………….

Answer only if you are suffering from neck pain: My neck pain/shoulder pain/upper back pain is…………….

Sleep Pain wakes you from sleep every day , occasionally frequently but not every day How many hours do you sleep at night__________________________ Do you fall sleep during the day yes No Have you ever taken medication for sleep ______ which one _______________ Headaches: My headaches are…………….

When having headaches…………….

The treatments I have received so far includes……………

Comments: _____________________________________________________________________


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I have seen the following for the problems I am having………….. _______________ date of first visit___________ and date of last visit ______________

-surgeon __________________________________________________________________________________ geon ___________________________________________________________________________

_____________________________________________________________________________________ ______________________________________________________________________________________

______________________________________________________________________ __________________________________________________________________________

Physical therapist__________________________________________________________________________________ Others ______________________________________________________________________________________________ I have undergone these tests for the current problem……………

-Rays__________________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

_________________________________________________________________________

______________________________________________________________________ EMG/Nurve conduction studies Blood tests ______________________________________________________________________________________ Others___________________________________________________________________________________________ Comments:__________________________________________________________ Please check what have been used to treat your current condition, where and when

o Physical therapy o Traction o Chiro practice adjustment o Acupuncture o Epidural injection o Other injection

o Tens units o Pain/stress management o Counseling o Surgery

Do you have allergy to any of the following Medications ___ ____ ; if yes list and reaction_____ ________________________ Xray contrast dye Iodine/shelfish Latex Food Others Do you have allergy to any of the Medications ____________________________________ Do you take blood thinners yes or no _____________________________________________


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Are you taking any of the following meds: Aspirin Coumadin (warfarin), Lovenox , Plavix, Pradaxa, Brillinta, Xarelto Please list ALL medications you are CURRENTLY taking: including the over counter and herbal medications, vitamins

Medications: include any over-the-counter medications, like multivitamins/eye drops. If

you brought your medications today, you do not have to write the medications down.

Name Dose or Strength How many times a day

1. ____________________________________________________________ 2. ____________________________________________________________ 3. ____________________________________________________________ 4. ____________________________________________________________ 5. ____________________________________________________________ 6. ____________________________________________________________ 7. ____________________________________________________________ 8. ____________________________________________________________

Please check the medications you have taken IN THE PAST for any reason:

Others: ______________________________________________________________________


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Please list all past Hospitalizations _________________________________________________________________________________________________________________________________________________________________________________________________________________ Pervious surgeries: __________________________________________________________________________________________________________________________________________________________________________________________________________________ Please any other medical conditions __________________________________________________________________________________________________________________________________________________________________________________________________________________ Please tell us if you are or if you have in the past suffered from any of these conditions:

High Blood pressure yes no Angina Heart Attack / heart disease Stroke Diabetes Thyroid Problems Overweight Cancer Seizures/Epilepsy Depression Bipolar/ schizophrenia Asthma / COPD/ emphysema

Ulcers/ stomach problems Intestinal problems Hepatitis/Jaundice Kidney Problems Major accident Arthritis Bleeding tendencies Breathing problems Difficulty with anesthesia Malignant hyperthermia ________________________

Please tell about your close relatives: Father Mother I have _______ brother(s) and ________ sister(s). ____________________________ Brother #1 Problems: ____________________________ Brother #2 Brother #3 Sister #1 h Problems: ____________________________ Sister #2 Sister #3 I have ______ son(s) and ________ daughter(s). Comments: __________________________________________________________________________


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Please tell us tell us about yourself, family, employment and habits: I am: separated I live with I am: If working, I am employed as: ________________________________________________________ Type of work and hours of work My current employer My previous employer Are currently receiving disability when started reason for disability Education: - Exercise: In a day of work or living How many hours you spend Sitting Driving Standing Lifting weight Walking How much you like your job 1 to 10 Do you feel your pain preventing you to work Rate your anger Rate your level of anxiety/ depression, nervousness low 1-10. high Alcohol use: In the past year, I have used: I had problems with: Problem with alcohol, DUI, Problem with illicit drug abuse Convicted or charge with drug or alcohol abuse Have you ever participated in alcohol or drug abuse


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I use tobacco _________________ Chew: how much and for how long Cigar: how much and for how long___________ Cigarette Smoker: Decline to state If ever smoked: Age started smoking __________ Yrs. Type of material

Packs per day _______________ Tried to quit? If yes, age quit smoking _______ Yrs Planning to quit? Modalities to help quit smoking:

Chantix, Zyban Comments: __________________________________________________________________________ Review of systems Within the past year, have you suffered from the following? Constitutional: Dermatology: , skin sores or ulcers Ophthalmic: ENT: ENT: Respiratory: Cardiology: , heart racing GI: , vomiting, GI: Musc/Skeletal: swelling Musc/Skeletal: Neurology: Neurology: , speech difficulty, walking difficulty, loss of consciousness Paralysis, sensory disturbance, rt/left arm leg Hematology: nodes, blood clot Psychology: bipolar, schizophrenia Urinary loss of bladder CONTROL, immediate need for urinate, having urinate at night Females: - Males: - - Endocrine: low or high sugar Sleep snoring insomnia day time sleepiness , fatigue Allergy: Eye vision loss , blurred vision Comments: __________________________________________________________________________


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This questionnaire will become part of your medical record in the pain clinic. Any

false information or omission may lead to termination of treatment from pain

management. Complication and side effects due to falsification or omission are

responsibility of the patient.

I verify that information in this form is accurate and complete.

Name of patient ________________________________________________________________________

Signature ___________________________________________ Date:___________________


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Appointment Cancellations and “No Show” Policy

We expect that our patients will keep their appointments, which are setup with mutual agreement. There are always several patients, who would like to be treated sooner, but have to wait for their turn, as this clinic is very busy. When a patient does not show up for his/her appointment or does not give adequate cancellation notice, that time slot is wasted, which could have been utilized to take care of other patients, especially for those who would like to get in sooner. This clinic reserves a right to bill the patients a fee for not showing up or not giving adequate notice for a scheduled appointment. The “No Show” fee is $ 50 for a procedure appointment or initial consultation. Please note that your insurance company will NOT pay this amount and you will be personally responsible for the fee. We may NOT reschedule your appointment until this fee is paid. Certainly, we will use discretion while implementing this policy as we realize that true emergencies do occur. If you are being treated under Worker’s Compensation insurance, we are also required to notify your Work Comp Adjuster and it may affect your benefits. I have read the above “Appointment Cancellations and “No Shows” Policy”. I agree that FFHC Medical Clinic reserves a right to bill me for not showing up at a scheduled appointment, or for not giving adequate notice of cancellation. I further agree that I may not be rescheduled if I do not pay the “No-Show” charge billed to me. __________________________________ ________________________ Signature Date


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Authorization for collection, use, and release of Personal and Medical Confidential

Information

Name of patient ________________________________________________________________________

HIPAA (Healthcare Insurance Portability and Accountability Act of 1996) restricts collection, use, and sharing of confidential medical and personal information. This information includes items such as Name, Age, Date of Birth, Tel Numbers, address, Social Security Number, Information about your health, work, employment, family, medication use, diagnostic data, health insurance, email address, digital facial photographs etc. At The Family First Healthcare (FFHC), we use the information obtained from you, your referring physician and other related healthcare providers, insurance carriers, pharmacies, and diagnostic facilities for the purpose of: • Scheduling for consultations and treatments at FFHC and other healthcare facilities • Evaluation and treatment • Identifying a particular patient to locate him/her within waiting areas • Discussing diagnosis and treatment plan with staff and other health providers at FFHC • Discussing diagnosis and treatment with your family members or guardian • Referring you for further diagnostic studies (X-Ray, MRI, CAT Scan, Blood Work etc) • Referral to other providers such as Consultants, Physical Therapists, Surgeons, Psychologists etc • Calling in, Faxing, or confirming prescriptions to pharmacies • Billing and collection firms’ use • Sending reports to your attorney, insurers, nurse case manager, W/C adjuster • Dictation transcribing companies’ use • Sending information to other persons or firms where you have signed a valid “Release of Information “The information is stored in paper charts and computers at FFHC and is shared via Fax, E-Mail, Mail, Telephone, Internet, and personal communications. We share as minimum information as possible for an appropriate use. FFHC does not to provide, or sell, or market the information to commercial firms for marketing reasons. The HIPAA guidance clarifies that a health care provider may rely on his or her professional judgment in determining whether there is an emergency which would justify foregoing the consent requirement, as is permitted by the Privacy Standards.


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Name of patient ________________________________________________________________________

I understand the purpose of collection, use and release of confidential information about me by FFHC as listed above and I hereby authorize FFHC to collect, use, and release such confidential information about me, as needed for my medical care and financial liability. The information obtained or released by the clinic pursuant to the authorization may be subject to redisclosure by the recipient and may no longer protected. This consent can be revoked at any time by giving a written notice, except to the extent that disclosure made in good faith has already occurred in reliance on this consent. This consent will remain in effect while I am a patient at FFHC and for 180 days after my discharge from the FFHC Clinic. ____________________________________________ ______________________________ Signature Date


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Consent for Release of Information

To give you the best possible care, The Family First Healthcare (FFHC) needs to be able to obtain records of your treatment by other physicians and hospitals as well as copies of laboratory and x-ray tests. This consent authorizes us to obtain that information. All information obtained is treated as confidential and will not be disclosed outside of FFHC without your consent. I hereby authorize physicians, hospitals, clinics, and laboratories that have treated me to release information from my health records to: The Family First Healthcare (FFHC) 2005 Prince Ave Athens GA, 30606 706 2089700 [email protected] Information to be released includes:

-ray, and other diagnostic results

This consent can be revoked at any time except to the extent that disclosure made in good faith has already occurred in reliance on this consent. This consent will remain in effect while I am a patient at FFHC. Attending physicians and facilities, including their employees and officers are released from legal responsibility or liability from the release of information to FFHC.

Name of patient _________________________________________________ DOB______________________

________________________________________ ____________________ Signature Date

mailto:[email protected]


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Medication Risks Acknowledgement It is very important to us that you understand that we may be prescribing one or more of the following medications* to you. You may already be taking one or more of these; however we may increase or decrease the dosage of your medication(s) or discontinue at any time. *All opioids or Narcotics (e.g. Vicodin, Lortab, Oxycontin, Percocet, Percodan, Codeine, Norco, Morphine, Dilaudid, Tramado, Fentanyl, Opana, Exalgo etc). All Tricyclic-Antidepressants (e.g., Elavil, Triavil, Doxepin, etc). All anti-seizure type medication (e.g., Neurontin, Lyrica, Cymbalta, Tegretol, etc). All anti-depressants (e.g. Paxil, Prozac, Cymbalta, Effexor, Wellbutrin etc) All sedatives-benzodiazepines (e.g., Valium, Klonopin, Ativan, etc). All muscle relaxants (e.g., Flexeril, SOMA, Zanaflex, Baclofen, etc). Other medications as deemed necessary.

Taking medications containing aspirin, acetaminophen, or ibuprofen or other anti-inflammatory medications with alcohol may impair your liver or other organs.

These medications can cause impairment of mental and/or physical abilities necessary when driving or operating heavy equipment. These effects may be enhanced by use of alcohol and/or other Central Nervous System depressants. We advise you not to drive or operate heavy machinery while you are under the influence of sedating medications.

Stopping some of the medications suddenly can cause serious health problems. Please consult your physician or pharmacist if you have any questions or need further information about the side effects and risks associated with the use of these medications. I have read the above and understand the implications of using the above-mentioned Medications


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Pain Management Patient Care Agreement

I, ____________________________________ understand that in order to receive care for the treatment of pain at FFHC Pain Center, Lavonia., I agree to comply with the following: A. USE OF MEDICATIONS: I will take all medications as prescribed. I will speak with a provider at FFHC Pain Center, Lavonia. before making any change in either the dose or frequency of taking my medications. There will be no early refills of pain medications due to self escalation of medications. Pharmacy: Narcotic pain medications must all be obtained from the same pharmacy (any exceptions must be approved by FFHC Pain Center, Lavonia). My current pharmacy is ____________________________________ B. SEEKING PRESCRIPTIONS: I will neither seek nor fill prescriptions for any medications related to pain relief from any other health care provider unless authorized by FFHC Pain Center, Lavonia. C. MEDICAL RECORDS RELEASE: I will inform all of my health care providers that I receive pain management through FFHC Pain Center, Lavonia. and will maintain an unrestricted and current medical records release on file with FFHC Pain Center, Lavonia. I authorize FFHC Pain Center, Lavonia to provide a copy of the Pain Contract to release medical information to necessary pharmacies. D. MENTAL HEALTH: A mental health assessment and/or continuing psychological therapy may be required. If I am currently involved in mental health therapy, or if I enter such therapy, I will authorize my mental health practitioner to exchange unrestricted information regarding my condition and treatment with the healthcare providers of FFHC Pain Center, Lavonia. E. DRUG SCREENING: I will participate in drug screening as a part of my treatment plan. I understand that drug screening will be conducted at least every 12 months and may be required more frequently at the discretion of FFHC Pain Center, Lavonia. Screening may include urinalysis, blood testing and/or pill counts. I agree to pay any and all cost associated with drug testing not covered by my insurance. Refusal to submit to screening at the time specified may result in termination of service. F. ALCOHOL USE: Any use of alcohol with prescriptions is against clinic policy. Testing for alcohol use may be added to random and routine urine drug screens at the


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discretion of the physician. Any use of alcohol deemed inappropriate by the physician will be grounds for termination from FFHC Pain Center, Lavonia. G. ILLEGAL AND NON-PRESCRIBED DRUG USE: I understand that the use of any controlled medication, not prescribed by FFHC Pain Center, Lavonia, may result in termination of care. I authorize FFHC Pain Center, Lavonia to cooperate fully with any city, state, or federal law enforcement agency. I agree to waive any applicable privileged, right of privacy, or confidentiality with respect to these authorities. I also understand that the use of any illegal substance including marijuana will result in terminations of care by A.A. Pain Clinic. H. LOST OR STOLEN MEDICATION: I agree to safeguard all medication prescribed by FFHC Pain Center, Lavonia and understand that lost, stolen, or damaged medications will not be replaced. All stolen drug should be reported to local police department and copy of the police report should be brought to the pain clinic as soon as possible I. PRESCRIPTIONS WHILE TRAVELING: FFHC Pain Center, Lavonia. may choose to provide prescriptions for up to 60 days when I am traveling out of state. I will only be eligible for early medication when proof of travel can be obtained. Identification includes paper ticket and electronic confirmation sheet that shows how much I paid. I will have to arrange for shipment of controlled substances by my pharmacy at my own expense. If I will be out of state longer than 60 days, I need to arrange for my health care at my travel destination. On return to Your home in Georgia , I need to advise A.A. PainClinic of the name and address of my provider out of state. I also authorize A.A. Pain Clinic to contact my provider to obtain any detailed information deemed necessary in my medical care. J. DRIVING AND OPERATING EQUIPMENT: Many pain medications can cause drowsiness and/or a very relaxed state of mind causing operation of equipment or vehicles to be dangerous. I agree to refrain from driving or operating dangerous equipment for 72 hours after any change in medication dosage and whenever I feel drowsy. K. MISSED APPOINTMENTS: Please contact the clinic if you will be 5 to 10 minutes late. If I arrive later than 15min, I will be rescheduled. Three missed appointments per year are grounds for termination from AA Pain Clinic. L. CANCELLATIONS: As of September 1, 2008; we require a 24 hour notice to cancel or reschedule your appointment. Appointments missed, rescheduled due to tardiness, or rescheduled without a 24 hour notice will result in a $50.00 fee to the patient.


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M. CHARGES: All fees from patients are due at the time of visit. Non-payment of fees may result in account being sent to collections and patient termination from A.A. Pain Clinic. N. TERMINATION: I will no longer be eligible for care at FFHC Pain Center, Lavonia if I am in possession of illicit drugs or substance, trafficking in controlled or illegal substances, intoxicated or convicted for DUI. If I forge or alter the prescriptions in anyway, sell or share medications, or fail to comply with this contract, I will no longer be eligible for care at FFHC Pain Center, Lavonia I understand that this doctor may stop prescribing opioids or change the treatment plan if: a. I do not show any improvement in pain from opioids or my physical activity has not improved. b. My behavior is inconsistent with the responsibilities outlined in #1 above. d. I develop rapid tolerance or loss of improvement from the treatment. e. I obtain opioids from other than this doctor. f. I refuse to cooperate when asked to get a drug screen. g. If an addiction problem is identified as a result of prescribed treatment or any other addictive substance. h. If I am unable to keep follow-up appointments I. if I am in possession of illicit drugs or substance, trafficking in controlled or illegal substances, intoxicated or convicted for DUI. If I forge or alter the prescriptions in anyway, sell or share medications, O. TREATMENT OF STAFF: Our clinic has a zero tolerance policy for verbal abuse towards our staff. Swearing, yelling at, or threatening of our staff will result in termination from our clinic. P. EMERGENCY ROOM VISITS and Hospitalization: I am allowed to receive pain medication in the emergency room, but it is a violation of the FFHC Pain Center, Lavonia contract to receive narcotic medication to take home and must be discussed with the on-call doctor prior to receiving medication. A violation includes any prescription and/or samples. On visit to Pain clinic you should discuss your Emergency room visits and hospitalization Addiction: If I have an addiction problem, I will not use illegal or street drugs or alcohol. This doctor may ask me to follow through with a program to address this issue. Such programs may include the following: „ 12-step program and securing a sponsor „ Individual counseling „ Inpatient or outpatient treatment „ Other: __________________


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I HAVE THOROUGHLY READ THIS AGREEMENT BEFORE RECEIVING TREATMENT AT FFHC Pain Clinic, Athens; I UNDERSTAND AND AGREE TO THE CONDITIONS OF CARE DESCRIBED ABOVE AND WILL COMPLY WITH THEM. ALL OF MY QUESTIONS ABOUT THE TERMS OF THIS AGREEMENT HAVE BEEN ANSWERED. I KNOW THAT FAILURE TO COMLPY WITH ANY OF THESE TERMS OF THIS AGREEMENT MAY RESULT IN IMMEDIATE TERMINATIONS OF SERVICE. Reviewed contract and answered all patients’ questions MA __________________________________________________ Date: _____________ Patients’ Signature: ____________________________________ Date: _____________

Practitioner Signature: ________________________________ Date: _____________


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Opioid Risk Tool

Date _____________________________

Patient Name ________________________________________ MR# ____________________

o Mark each Item Score Item Score [ ]

o box that applies If Female If Male [ ]

o Family History of Substance Abuse Alcohol [ ]

o Illegal Drugs [ ]

o Prescription Drugs [ ]

o Personal History of Substance Abuse Alcohol [ ]

o Illegal Drugs [ ]

o Prescription Drugs [ ]

o Age (Mark box if 16 – 45) [ ]

o History of Preadolescent Sexual Abuse [ ]

o Psychological Disease Attention Deficit [ ]

o Obsessive Compulsive Disorder [ ]

o Bipolar, Schizophrenia [ ]

o Depression [ ]