fidelity health and wellness center, llc pain … · varicose veins peripheral vascular disease...

Page � of �1 16

!FIDELITY HEALTH AND WELLNESS CENTER, LLC

PAIN MANAGEMENT !Patient Name _____________________________________________________ DOB _________________________________

!Date of Initial Visit: ______________________________ PATIENT MEDICAL RECORD ID: _____________ !!

PATIENT REGISTRATION FORM Please complete all forms with blue or black ink only. !

PATIENT INFORMATION: Name: (Last) ___________________________________(First) ________________________(MI) ________ Suffix: ___________ !Maiden Name/Alias(es) used:___________________________________________________________________ !DOB: ________ -_________-___________ Age: ___________ SS # _______________________________ !Gender: Female Male Marital Status: Single Married Divorced Separated Widowed Engaged !Address:____________________________________City: ______________________State: _________ Zip Code: _________ !Home phone # ______________________________________ Work phone # ___________________________________ !Cell phone # _______________________________________ E-mail address: ___________________________________ !Do you have access to a computer with Internet? YES NO Would you like you medical information accessible through the Internet? YES NO !Driver’s License#:________________________________ State issued:_________________________ (Please give all available forms of identification to staff to include in your medical chart.) !!EMERGENCY INFORMATION Full Name:__________________________________ Relationship to patient: _______________________________________ !Phone(s): __________________________________________ !Address: __________________________________________ City:___________________State:______ Zip Code:________ !!RESPONSIBLE PARTY INFORMATION Last Name: _____________________________________ First Name:_______________________________ MI: ________ !Address: __________________________________________ City:___________________State:______ Zip Code:________ !Home Phone #:_____________________________________ Work Phone #:______________________________________ !Relationship to patient: ________________________________ !!

!!FIDELITY HEALTH AND WELLNESS CENTER, LLC !

Patient Name _____________________________________________________ DOB _________________________________ !HEALTH INSURANCE

Any form of health insurance? (Including Medicare, Medicaid/

State insurance, prescription) YES NO

[Please give insurance card(s) to the staff for record keeping in chart] !Primary Insurance Name: __________________________

Insured Last Name:________________________________

Insured First Name: ____________________ MI:_________

Insured SS#: _________________________

Insured DOB:______________________ Sex: M F

Policy/RID #:_____________________________________

Group #:________________________________________

Effective Date:____________________________________

Member ID #____________________________________

Employer: _______________________________________ !

!!Secondary Insurance Name: ________________________

Insured Last Name:________________________________

Insured First Name: ____________________ MI:_________

Insured SS#: __________________________

Insured DOB:______________________ Sex: M F

Policy/RID #:_____________________________________

Group #:________________________________________

Effective Date:____________________________________

Member ID #____________________________________

Employer: _______________________________________ !!!!REFERRAL INFORMATION

How did you hear about Fidelity Health and Wellness, LLC?

____________________________________________ !Were you referred? YES or NO !Referred By: ___________________________________ !

Address: ______________________________________ !City_____________________ State_________ Zip______ !Phone Number:___________________________________ !Referral Brought with you today? (Select one) YES NO

(please give referral form or letter to staff)!!EDUCATION

Are you a student? Yes □ No □ !If yes, FULL TIME PART TIME (circle one) !School Name ___________________________________ !!

!City___________________________State____________ !Highest Level of Education Achieved : High School/ Technical

school/ Vocational Program/ Associates Degree/ Bachelors

degree/ Masters Degree/ Doctorate !Degree Attained: _________________________________ !!

Page � of �2 16



!EMPLOYMENT HISTORY Retired? : YES NO Date of retirement: ___________________________ !Disabled? YES NO If yes, (select one) Temporary Permanent Case worker name________________________________ !State _______ Contact Phone number: ________________ !Date Disability started: _______________________ !Currently employed? YES NO If yes, (select one). FULL TIME PART TIME !Current Occupation: ______________________________ !# of hours worked per week: ______________hours/week !What does your work involve? ________________________ _______________________________________________ _______________________________________________ !

Current Employer:_________________________________ !Current Work Address: _____________________________ !City:__________________ State: ________ Zip: _________ !Phone #: ________________________________________ !If not working, time since last unemployed? ____(months/years) !Do you wish to return to work? (Select one) YES NO !Previous Employer:_________________________________ !Address: ________________________________________ !City: __________________ State: ________ Zip: ________ !Phone #_________________________________________ !Why did you leave?_________________________________ !

!LEGAL INFORMATION Presently involved in a lawsuit? Yes No !Please provide details: ______________________________ _________________________________________________ !Attorney Name/Office:______________________________ !

Address:________________________________________ !City ___________________ State:________ Zip:________ !Office Phone number:________-_________-________ !Fax #: _________-________-___________

!Workman’s Compensation?: (Please circle one) Yes No !Name of Company:_______________________________ !Contact Name: __________________________________ !Phone #________________________________________ !Date of Injury:___________________________________ !Employer at time of Injury: __________________________ !

Employer Phone #:________________________________ !Car accident or Personal Injury case: Yes No !If yes, explain_____________________________________ !Contact Information: _______________________________ !Felony/Misdemeanor Case: (Select one) Yes No !If yes, explain____________________________________ _______________________________________________ !!

!

Page � of �3 16


Patient Name _____________________________________________________ DOB _________________________________ !!GENERAL HEALTH OVERVIEW

Primary Care Physician’s Name/ Group:____________________ Phone #_________________________________________ !Address: _____________________________________________ City: _____________________State: _______Zip:________ !If No PCP, when and where did you last receive medical care and for what reason?

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________ !!Height: ___________________ Weight: _____________________

ALLERGIES

Are you hypersensitive, intolerant or allergic to: !Any drugs, medications, injections?

Please

indicate___________________________________________ !Penicillin or other antibiotics Yes No

Demerol or other narcotics Yes No

Aspirin or other pain relievers Yes No

Morphine Yes No

Novocain or other anesthetics Yes No Tetanus

antitoxin or other serums Yes No

Iodine, merthiolates or other antiseptics Yes No !Any foods? ______________________________________ !Any chemicals or environmental substances______________ !Any side effects experienced to medications taken in the past

such as gastritis, nausea, or vomiting_____________________ !Have you ever had an allergy test? If yes, indicate when and

explain: _________________________________________ !Have you ever had diffiuclties with spinal , epidural or

anesthetics? ______________________________________ !

Page � of �4 16



!MEDICAL HISTORY (Please circle all that apply)

Head/Eyes/Ears/Nose/Throat None

Cataract Glaucoma

Sinus Infection

Neurological/Psychological None

Headache TIA (mini stroke) Multiple Sclerosis Stroke/Paralysis Seizure/Epilepsy

Depression Anxiety

Eating Disorder

Heart None

Rheumatic fever Heart Failure

Abnormal Heart Rhythm High Blood Pressure

Endocrine None

Thyroid Disease Diabetes Mellitus Juvenile Diabetes

Gestational Diabetes

Lung None

Asthma Sleep Apnea Tuberculosis

Emphysema/COPD Pneumonia

Hematological/Oncological None

Cancer (Type) _____________________________ Chemotherapy

Radiation Anemia

Blood Clot (Leg _______ Lung ______ Other ______) Bleeding Tendency

Gastrointestinal None

Stomach/Duodenal Ulcer Cirrhosis

Hepatits (Type) ___________ Gallstones

Pancreatic Disease Esophagus Disease

Crohn’s or Colitis Diverticulitis

Acid Refulx/GERD

Peripheral vascular Aneurysm

Varicose Veins Peripheral Vascular Disease (PVD)

Genitourinary None

Kidney Infection Kidney Stones Kidney Failure

Dialysis Prostate Problems

Skin Skin Ulcer Psoriasis

Rash

Page � of �5 16



!MEDICAL HISTORY (Please circle all that apply)

Head/Eyes/Ears/Nose/Throat None

Cataract Glaucoma

Sinus Infection

Neurological/Psychological None

Headache TIA (mini stroke) Multiple Sclerosis Stroke/Paralysis Seizure/Epilepsy

Depression Anxiety

Eating Disorder

Heart None

Rheumatic fever Heart Failure

Abnormal Heart Rhythm High Blood Pressure

Endocrine None

Thyroid Disease Diabetes Mellitus Juvenile Diabetes

Gestational Diabetes

Lung None

Asthma Sleep Apnea Tuberculosis

Emphysema/COPD Pneumonia

Hematological/Oncological None

Cancer (Type) _____________________________ Chemotherapy

Radiation Anemia

Blood Clot (Leg _______ Lung ______ Other ______) Bleeding Tendency

Gastrointestinal None

Stomach/Duodenal Ulcer Cirrhosis

Hepatits (Type) ___________ Gallstones

Pancreatic Disease Esophagus Disease

Crohn’s or Colitis Diverticulitis

Acid Refulx/GERD

Peripheral vascular Aneurysm

Varicose Veins Peripheral Vascular Disease (PVD)

Genitourinary None

Kidney Infection Kidney Stones Kidney Failure

Dialysis Prostate Problems

Skin Skin Ulcer Psoriasis

Rash


Patient Name _____________________________________________________ DOB _________________________________ !

Any other medical conditions:___________________________

___________________________________________________

___________________________________________________ !!

Do you have any known contagious diseases at this time?

(Please circle one) YES NO

If yes, please indicate condition and how long? ___________

__________________________________________________

!PSYCHIATRIC HISTORY (Place a check mark if applicable)

_____Depression ____Anxiety _____Anger ____Mood Swings

_____Tension ____Other:_______________________________________________ !Under psychiatric care with:________________________________________ Phone #____________________________________ !!PAST SURGICAL HISTORY RELATED TO PAIN

Previous Surgeries (as related to the pain such as a laminectomy): (please indicate hospital and doctor/surgeon name)

!PAST SURGICAL HISTORY NOT RELATED TO PAIN

Musculoskeletal None

Rheumatoid Arthritis Gout

Lupus Serious Joint Injury Broken bone injury

Degenerative Arthritis

Other Alcoholism

Drug Abuse Immune Deficiency

Chronic Fatigue Syndrome Other ________________________________________ Other ________________________________________

Surgery Date Surgery Date

Surgery Date Surgery Date

Page � of �6 16



!OB/GYNE HISTORY (Females Only)

Still have periods? YES NO !Regular monthly menstrual periods? YES NO

If no, explain: IRREGULAR?___________________________ !Menopause? YES NO !Hysterectomy or tubal ligation?________________________ !Heavy cycles? YES NO

# of days that period lasts? ___________________________ !History of Miscarriages YES NO !Ectopic Pregnancies YES NO !!

!!Abortions YES NO !Birth Control/OCPs YES NO !Date of last Pap smear: _____________________________ !Date of last Gyne Check-up :_________________________ !# of Children: ___________________________________ !# of Cesarean Sections? ____________________________ !# of Normal deliveries? (NSD/vaginal?)__________________ !# of children or grandchildren residing with you? __________ !Ages of children:__________________________________ !

!PERSONAL/SOCIAL HISTORY

With whom do you live? _____________________________ !Supportive relationship? YES NO !History of physical or emotional abuse? YES NO

Please provide details: _______________________________ !Are there any substance abuse issues/concerns in the

household? If yes, please explain:_______________________

__________________________________________________ !Physical abuse concerns? Explain: ______________________

__________________________________________________

!Are you able to take care of yourself? YES NO

If NO, name of caregiver:____________________________ !Main interests and hobbies? __________________________ !Activity Level: (select one) sedentary active

Exercise? (Select one) YES NO

Type of exercise:_______________# times per week ______ !Do you wear your seat belt? (Select one) YES NO !Do you have a religious/spiritual practice? YES NO

If yes, PLEASE INDICATE? ___________________________ !!

Page � of �7 16


Patient Name _____________________________________________________ DOB _________________________________ !!SUBSTANCE ABUSE

Tobacco Use? YES NO

Have you ever smoked cigarettes? (Select one) YES NO !Amount per day: ____________packs/day for ________ years !If you have quit smoking, when did you stop?______________ !Alcohol Use? YES NO

If yes, frequency? □ Daily □ Few per week □ Special Occasions

□ Rarely !Type of alcohol_________________________________ !History of alcohol abuse? (Select one) YES NO !History of Treatment of any kind? (Select one) YES NO !WHERE_____________________________________________

___________________________________________________ !History of drug or illicit substance abuse? (Select one)

YES NO

!ANY Treatment? (Select one) YES NO

WHERE?____________________________________________

___________________________________________________ !Which of the following drugs or substances, if any, have you

used in the PAST or PRESENTLY USING ? (Check all that apply)

Next to each drug/substance checked, please indicate if you

used it: Occasionally ("O"), Frequently ("F"), or Continuously

(“C”). Indicate Date of Last Use if applicable. !Alcohol ____ O F C Date: _________ !Barbiturates ____ O F C Date: _________ !Cocaine _____ O F C Date: _________ !Heroin _____ O F C Date: _________ !Other ______ O F C Date: _________ !Amphetamines ___O F C Date: _________ !Marijuana _____ O F C Date: _________ ! !

!

Page � of �8 16



!PAIN HISTORY

Briefly list the main reason(s) for your visit today: ______________________________________________________________ !How did your pain problem first start (Describe)? ______________________________________________________________ !How long have you had this pain? __________________________________________________________________________ !Please describe what your pain is like: (Please circle all that apply) Sharp

Shooting

Burning

Pressure

Throbbing

Cramping

Achy

Constant

Stabbing

Gnawing

Tender

Comes and goes!When is your pain the worst? Morning Afternoon Evening Night Varies All of the time !Are you awakened at night by your pain? YES NO !What improves your pain? _______________________________________________________________________________ !What worsens your pain? _______________________________________________________________________________ !!At any given time, think of your pain intensity as falling somewhere on a scale of 0 to 10. Please rate your pain on the following

diagrams:

0= No pain 10=Very severe pain !

!!

Page � of �9 16



!PAIN HISTORY

Briefly list the main reason(s) for your visit today: ______________________________________________________________ !How did your pain problem first start (Describe)? ______________________________________________________________ !How long have you had this pain? __________________________________________________________________________ !Please describe what your pain is like: (Please circle all that apply) Sharp

Shooting

Burning

Pressure

Throbbing

Cramping

Achy

Constant

Stabbing

Gnawing

Tender

Comes and goes!When is your pain the worst? Morning Afternoon Evening Night Varies All of the time !Are you awakened at night by your pain? YES NO !What improves your pain? _______________________________________________________________________________ !What worsens your pain? _______________________________________________________________________________ !!At any given time, think of your pain intensity as falling somewhere on a scale of 0 to 10. Please rate your pain on the following

diagrams:

0= No pain 10=Very severe pain !

!!


Patient Name _____________________________________________________ DOB _________________________________ !!In each section, Check one item that best describes you pain. If the section has no description that applies to your pain, please skip

that section

!!

!

flickering

quivering

pulsing

throbbing

beating

pounding

pinching

pressing

gnawng

cramping

crushing

dull

sore

hurting

aching

heavy

fearful

frightful

terrifying

spreading

radiating

penetrating

piercing

lumping

flashing

shooting

lugging

pulling

wrenching

tender

taut

rasping

splitting

punishing

grueling

cruel

vicious

killing

light

numb

drawing

squeezing

tearing

pricking

boring

drilling

stabbing

lacinating

hot

burning

scalding

searing

tiring

exhausting

wretched

blinding

cold

cool

freezing

Page � of �10 16



What were you doing when it first happened?____________ !When did it happen again?_____________________________ !Did you go to a doctor or hospital?_____________________

Where?____________________________________________

When?_____________________________________________ !Did you take anything?________________________________

Were you prescribed any medications or therapies? WHAT?

__________________________________________________ !Any diagnostics studies done?__________________________

WHERE? ___________________________________________

WHEN? ____________________________________________ !Did the doctor/hospital refer you to any doctors or for

follow-up ?__________________________________________

WHO? _____________________________________________

WHERE? ___________________________________________

!How bad does it get? _____________________/10

(0-10. 0= no pain, 10 = worst pain of your life) !Does it stay in one area or do you feel it in other places?

If yes, Where? ______________________________________ !Is it every day? YES NO !DId anyone tell you what was wrong? ___________________

Any other details? ___________________________________ !On a scale of 0-10, please indicate the PAIN LEVEL:

O= no pain, 10= worst pain of your life

Pain Level Today _____/10

Average level _____/10 without taking any medication

Average level _____/10 while taking any medication

Pain at Rest _____/10

Pain with Movement _____/10

!!!On the diagram, shade the areas where you feel the pain: !!!!!!!!!!!!!!!!

Page � of �11 16



!Have you ever been referred or used any of the following alternative treatments? (Please complete the table below)

!CURRENT MEDICATIONS/ SUPPLEMENTS

Please list any prescription, over the counter (OTC) medications, or vitamins/ supplements you are currently taking including dosages: !PRESCRIPTION MEDICATIONS

!OTC MEDICATIONS (Ibuprofen, NSAIDS, Antacids, sleep aids, laxatives)

!VITAMINS/ SUPPLEMENTS

!

Adjunctive treatment

Referred by Done by Address City, State Phone # Dates

Occupational/Physical Therapy ChiropractorAcupunctureMassageHydrotherapyNerve BlocksTENS UNITBiofeedbackHypnosisCounseling

Prescription Medications (Name) Dose (mg) Frequency (How many times a day) Prescribed by:1.

2.

3.

4.

5.

Medications (Name) Dose (mg) Frequency (How many times a day) How long?1.

2.

3.


2.

3.


Patient Name _____________________________________________________ DOB _________________________________ !Previous Pain Clinic/Doctor: _____________________________________________________________________________ !Address:___________________________________________________City_____________________State_____________ !Phone # _______________________________________ Fax: ________________________________________________ !Other Pain Management Clinic or Doctor seen:_______________________________________________________________ !Address:___________________________________________________City______________________________State_____ !Phone # _______________________________________ Fax: ________________________________________________

!OPIATE HISTORY:

Have you taken any of the following medications now or in the past? (Please circle all that apply) OXYCODONE

PERCOCET

METHADONE

OXYCONTIN

OPANA

HYDROCODONE

TRAMADOL

FENTANYL

LYRICA

GABAPENTIN

SOMA

XANAX

VALIUM

ATIVAN

IBUPROFEN

FLORINAL

FLEXERIL

OTHER _____________ !

Please specify below information for those noted to be taken:

!Any adverse reactions or side effects to the medications noted above? (Select one) YES NO

If yes, please indicate details: ____________________________________________________________________________ !Have you ever taken SUBOXONE? YES NO If yes, please explain ______________________________ !Have you ever been to an In or Outpatient rehabilitation clinic, center, or program? (Please circle one) YES NO

If yes, please

explain_____________________________________________________________________________________________ !Any other medications taken for pain: ______________________________________________________________________ !

Medications taken (Name)

Dose (mg) Frequency (how many times per day)

Prescribed by (Dr?) When? (dates)

Page � of �12 16



!Have you ever been referred or used any of the following alternative treatments? (Please complete the table below)

!CURRENT MEDICATIONS/ SUPPLEMENTS

Please list any prescription, over the counter (OTC) medications, or vitamins/ supplements you are currently taking including dosages: !PRESCRIPTION MEDICATIONS

!OTC MEDICATIONS (Ibuprofen, NSAIDS, Antacids, sleep aids, laxatives)

!VITAMINS/ SUPPLEMENTS

!

Adjunctive treatment

Referred by Done by Address City, State Phone # Dates

Occupational/Physical Therapy ChiropractorAcupunctureMassageHydrotherapyNerve BlocksTENS UNITBiofeedbackHypnosisCounseling

Prescription Medications (Name) Dose (mg) Frequency (How many times a day) Prescribed by:1.

2.

3.

4.

5.


2.

3.


2.

3.

Page � of �13 16


Patient Name _____________________________________________________ DOB _________________________________ !!

FAMILY HISTORY (Please indicate which are medical conditions prevalent and to whom in your family?) □ OBESITY __________________________

□ HIGH CHOLESTEROL ___________________

□ DIABETES__________________________

□ LUNG DISEASE/ASTHMA/EMPHYSEMA

__________________________________

□ ALLERGIES__________________________

□ HIGH BLOOD PRESSURE _________________

□ KIDNEY DISEASE _____________________

□ HEART DISEASE/STROKE _______________

□ BLEEDING DISORDER __________________

□ CANCER__________________________

□ AUTOIMMUNE DISORDERS______________

□ OSTEOPOROSIS_____________________

□ PSYCHIATRIC (DEPRESSION, EATING DISORDER,

ALCOHOLISM) _______________________________

□ OTHER_______________________________________

□ OTHER ______________________________________!REVIEW OF SYSTEMS: Check all that apply. . Have you experienced any of the following symptoms in the past 4 weeksGeneral

None

weight change

appetite change

fever, chills, sweats

dizziness, fainitng

Head/Eyes/Ears/Nose/Throat

None

vision change

hearing change

dry mouth

difficulty swallowing

mouth sores

Cardiopulmonary

none

shortness of breath

chest pain

swollen ankles

coughing up blood

rapid heart rate

Gastrointestinal

None

heartburn

nausea

abdominal pain

constipation

diarrhea

bleeding from the rectum/black colored bowel movements

Genitourinary

None

problems with passing urine

urine leakage

menstrual problems

I may be pregnant

pain with passing of urine

Musculoskeletal/Neurological

None

Headache

Joint pain

joint swelling

stiff muscles

painful muscles

weakness

numbness/tingling sensation Where? __________________________

back pain

neck pain

Skin

None

rashes

skin ulcers

Peripheral Vascular

None

Cool hands/feet

Color change

Leg pain when walking

Page � of �14 16



!PHYSICIANS SEEN IN THE PAST

!!

HOSPITALS

Have you been to any of the following hospitals? (Please circle all that apply) SOUTHERN MD

CALVERT MEMORIAL

NOVA

CIVISTA MEDICAL CENTER

ST, MARY’S COUNTY

PRINCE GEORGES COUNTY

HOSPITAL

ANNE ARUNDEL MEDICAL CENTER

PG SHOCK TRAUMA

JOHNS HOPKIN’S MEDICAL CENTER

WASHINGTON HOSPITAL CENTER

HOWARD

GEORGE WASHINGTON UNIV MC

GEORGETOWN UNIVERSITY

HOSPITAL

OTHER:_______________________

OTHER:_______________________!

!

Doctor/Group Name

Type Phone # Fax # Address, City, State Date last seen

PCPPain managementOrthopedicNeurologist Dentist

Hospital Name City, State

Phone# Fax # Reason for last visit

Date of last visit

Page � of �15 16


Patient Name _____________________________________________________ DOB _________________________________ !!

PREVIOUS LABORATORY WORKUP (Please include all laboratory workup done including hospitals)

!!

PREVIOUS DIAGNOSTICS: MRIS, XRAYS, CT-SCANS, EMG-NCV, Myelogram

(Please include all diagnostic workup done in the table below.)

!!

PHARMACIES USED

(Please circle all that apply and give specific details below) CVS

RITE AID

WALGREENS

ACCOKEEK

FRIENDLY

FAMILY CARE 1,2, 3

TIDEWATER

TARGET

WAL-MART

SAM’S CLUB

NORTH GATE CARE

REYNOLD’S

PROSPERITY

OTHER________________________

OTHER________________________!

Location Name

Phone# Address, City, State

Diagnostic done Date of last workup done

LabCorp

Quest

Kaiser

Diagnostic done Location Name Phone# ADDRESS Date done

Pharmacy Name Phone# Location Date of last visit

Page � of �16 16

fidelity health and wellness center, llc pain … · varicose veins peripheral vascular disease...

Documents