ffhc Pain Management - Family First Healthcare of Northeast Georgia
Family First HealthCare of NEGA Pain Management Clinic FAMILY FIRST HEALTHCARE OF NEGA, LAVONIA, GEORGIA Pain Management Clinic New Patient Packet Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic We want to welcome you to our Pain Management Center. We are dedicated to providing cost effective timely care for our local population. Our physicians and providers are specialized in the treatment of chronic pain. Hours of Operation: The Pain Management Clinic hours are from 8 AM to 5:00 PM Friday in our Lavonia office. Initial Visit: Your initial consultation visit takes about 1 hour and is usually an evaluation only. At your consultation visit you will be assessed by one of our specially trained nurse practitioners and your treatment history and goals will be discussed. After your examination is completed we will answer questions, talk about a plan of care and schedule your appointment with the physician. Before you will be seen by the physician: 1. You need to fill out a New Patient Questionnaire 2. Read, understand, and sign a pain management patient care agreement 3. Submit to a urine drug screen 4. Complete an Opioid Risk Tool questionnaire 5. Sign a 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. Sign a Medication Risks Acknowledgement 9. Understand we will search your prescription history: using Georgia PDMP Appointment: If you need to cancel your appointment, 24 hours notice is required. Failure to give adequate notice will result in a charge of $ 50 for “no show”. Contact Information: Telephone: 706-356-8181 Email: [email protected] Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Web Site: www.ffhealthcare.com Pain Management Patient Care Agreement Effective pain management requires that the patient and provider work together. This agreement is designed to make sure that you understand your obligations and the conditions of your care. Your care involves more than just taking pills. To be Successful, we have found that patients must also take responsibility to be active in their own care. We will ask you to set realistic goals and then we will work towards those goals together. Goals of Therapy What activities does your pain prevent you from enjoying? (Begin with the most important activity). 1.____________________________________________________________________ 2.____________________________________________________________________ 3.____________________________________________________________________ Self-care goals (for example, “bathe self daily”) 1.____________________________________________________________________ 2.____________________________________________________________________ 3.____________________________________________________________________ Family/social goals (for example, “attend son’s baseball games”) 1.____________________________________________________________________ 2.____________________________________________________________________ 3.____________________________________________________________________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Mobility goals (for example, “climb one flight of stairs”) 1.____________________________________________________________________ 2.____________________________________________________________________ 3.____________________________________________________________________ Work goals (for example, “return to work X number of days/week”) 1.____________________________________________________________________ 2.____________________________________________________________________ 3.____________________________________________________________________ If it is not possible to get back to 100% with these activities, what improvements in your ability to do these activities would you consider significant enough to make your quality of life better? 1.____________________________________________________________________ 2.____________________________________________________________________ 3.____________________________________________________________________ In your own words (but not using the word pain) how will we know that this treatment is working for you? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Pain Management Patient Initial Visit Last Name______________ First Name__________________ Middle Initial_______ Gender: Male Female Date of Birth: __________________________ Social Security Number: _______________________________________________ Address: _______________________________________________ _______________________________________________ City, State, Zip Tel: ( Work: ( ) _______-____________ Cell: ( ) _______-______________ ) _______-__________ E-mail:_____________@___________________ Referring Provider: _________________________________________________ Regular Primary Provider: ____________________________________________ My Height: ____________ Feet ________ Inch My Weight: ________________ Lbs. I am: Right handed Left handed Ambidextrous Main Reason for this visit? ______________________________________________________________________ ______________________________________________________________________ My pain started after…………. when An Injury Surgery Auto accident Injury at work Chronic illness Other where description 3. Do you have a Lawyer regarding your pain? Name of the lawyer_________________________________________________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic In you own words what do you think causes your pain?_________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ When did your pain Begin: Date______ Month______ Years_________ How long have you had pain: less than 3 months 6 months 1 year, >5 years, >10 years Please rate the intensity of your pain on this scale from 0 to 10. A rating of 0 means ‘no pain at all.’ A rating of 10 means ‘the worst possible pain you could imagine. Please rate your pain: My WORST Pain score: |_____|_____|_____|_____|_____|_____|_____|_____|_____|_____| 0 1 2 3 4 5 6 7 8 9 10 My LEAST Pain score: |_____|_____|_____|_____|_____|_____|_____|_____|_____|_____| 0 1 2 3 4 5 6 7 8 9 10 Please mark the areas of your pain above. Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic 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) Worse in the morning Worse in the evening Worse in the night Time of the day or night has NO association with my pain. 24-7 The type of pain I feel is………….. Burning Aching Throbbing Shooting Electric Shock Sharp Tight Stabbing I also have associated………….. Numbness Coldness Tingling Pins/Needles Weakness Stiffness Spasms Sensitive to touch Increased sweating Color changes Bladder problems __________________ My pain gets worse with………….. Sitting Standing Walking Laying down Leaning forwards Arching backwards Coughing/Sneezing My pain gets better with…………… Medications Rest Heat Ice Pack Relaxing Exercises Laying down Medical Marijuana Alcohol Straining ___________ Because of my pain, I have problems with…………. Falling asleep Staying a sleep Wake up frequently Pain does not affect my sleep Answer only if you are suffering from neck pain: My neck pain/shoulder pain/upper back pain is……………. Worse looking up Worse looking down Both same No change up or down Looking right Looking left Both same No change right or left Sleep: Pain wakes you from sleep: Every day, occasionally, frequently but not every day How many hours you sleep at night__________________________ Do you fall asleep during the day? Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Yes No Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Have you ever taken medication for sleep? Yes No Answer only if you are suffering from headaches: My headaches are……………. More on the right More on the left Both same More in the back of skull More in the front (behind eyes) When having headaches……………. Bright lights bother Loud noises bother More on the top of head No change with them The treatments I have received so far includes…………… Medications Physical Therapy Surgery Chiropractic Injections Massage Therapy Psychotherapy Acupuncture Comments: ______________________________________________________________________ I have seen the following for the problems I am having………….. Family MD address______________________ date of first visit_________________ and date of last visit __________________________ Neuro-surgeon Spine/Ortho Surgeon Chiropractor Neurologist Psychologist/Psychiatrist Pain Clinic ___________ Physical therapist Others I have undergone these tests for the current problem…………… X-Rays CT Scan MRI Scan Myelogram Nerve Testing (EMG) Bone Scan _____________ EMG/Nerve conduction studies Blood tests others Comments:_________________________________________________________Please check what has been used to treat your current condition, where______________________________________________________ when_______________________________________________________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Physical therapy Chiropractic Adjustment Tens Units Pain/Stress management Pain Management Clinic Traction Acupuncture Counseling Epidural Injection Other Injection Surgery Do you have allergy to any of the following: Medications ? Yes or No If yes, list and reaction__________________________________________________ X-ray contrast dye____________________ Iodine/Shelfish______________________ Latex_______________________________ Food_______________________________ Others______________________________ Do you take blood thinners? Yes or No Are you taking any of the following medication? Aspirin Coumadin(warfarin) Lovenox Plavix Pradexa Please list ALL medications you are CURRENTLY taking: including over the counter and herbal medications, vitamins etc...... Name Pill strength Amount at a time How often? e.g: Advil 200 mgs 2 to 3 tablets 3 times a day e.g: Norco 10/325 1 tablet every 6 hours ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Please check the medications you have taken IN THE PAST for any reason: Norco/Vicodin/Lortab Percocet/Percodan Ultram/Tramadol Codeine Darvocet Nucynta OxyContin Kadian/Embeda MS Contin Avinza Fentanyl Patch Dilaudid Advil/Motrin/Ibuprofen Naprosyn Aleve Celebrex Neurontin/Gabapentin Lyrica Cymbalta Elavil Trazodone Nortriptyline Effexor Wellbutrin Prozac Paxil Lexapro Celexa Remeron Zoloft Flector Patch Lidoderm Tylenol BenGay Aspercream Capsasin Flexeril SOMA Baclofen Zanaflex ParafonForte Robaxin Skelexin Valium Klonopin Xanax Ativan Ambien Lunesta Sonata Rozerem Restoril Provigil Nuvigil Retalin Adderall Exalgo Voltaren Gel Opana Methadone Butrans Suboxone Subutex Gralise Others: ______________________________________________________________________ Please list all past Hospitalizations: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ List all previous surgeries: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Please List any other medical conditions: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Please tell us if you or an immediate family member have in the past suffered from any of these conditions: High Blood Pressure Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Angina Heart Attack / Heart disease Stroke Diabetes Thyroid Problems Obesity 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 us about your close relatives: Father Living Deceased. Major Health Problems: ____________________________ Mother Living Deceased. Major Health Problems: I have _______ brother(s) and ________ sister(s). ____________________________ Brother #1 Living Deceased. Major Health Problems: ____________________________ Brother #2 Living Deceased. Major Health Problems: ____________________________ Brother #3 Living Deceased. Major Health Problems: ____________________________ Sister #1 Living Deceased. Major Health Problems: ____________________________ Sister #2 Living Deceased. Major Health Problems: ____________________________ Sister #3 Living Deceased. Major Health Problems: ____________________________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic I have ______ son(s) and ________ daughter(s). Comments: ______________________________________________________________________ Please tell us tell us about yourself, family, employment and habits: I am: Married I live with: I am: Single Divorced Spouse/Partner Retired Disabled Kids Widow separated Parents Working FT Alone Decline to state Friends Working PT Pet(s) Unemployed If working, I am employed as: ________________________________________________________ Type of work and hours of work _______________________________ My current employer________________________________________ My previous employer_______________________________________ Are currently receiving disability? When did it start? Reason for disability? __________________________________________________________ Education: School GED College Exercise: None Walk Go to gym Post-Grad. Trade School Yoga/Stretch Swim 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 prevents you from being able to work?_______ Rate your anger 1 to 10___________________________________ Rate your level of anxiety/ depression, nervousness 1 to 10_________________ Alcohol Use: Don’t drink Social In the past year, I have used: I had problems with: None Marijuana Alcohol abuse Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Heavy: _______ drinks per day Meth/Speed Drug abuse Cocaine Heroin None Prescription drug abuse Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic 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? Do you Use Tobacco? _____ yes _____ no Chew? how much and for how long?______________________________________ Cigar? how much and for how long?______________________________________ Smoker?: Daily Yes, but not every day Past Smoker Never smoked Decline If ever smoked: Age started smoking __________ Yrs. Type of material: Cigarettes Cigar Pipe Packs per day _______________ Tried to quit? Yes No If yes, age quit smoking _______ Yrs Planning to quit? Yes No Modalities to help quit smoking: Hypnosis Support Group Nicotine Patch Nicotine gum Prescription Medication (Chantix, Zyban etc) Self determination Comments: _____________________________________________________________________ Review of Systems Within the past year, have you suffered from the following? Constitutional: Dermatology: Fever Rash Ophthalmic: Appetite loss Dry skin Poor vision ENT: Trouble swallowing ENT: Hearing loss Respiratory: Cardiology: Skin Infections, : Blurred vision Cold Shortness of breath Chest pain Stomach pain GI: Difficulty swallowing Musc/Skeletal: Double vision Wheezing Blood in stools Bright lights bother Pneumonia Palpitations Constipation Heartburn Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 skin sores or ulcers Sore throat Dizziness Weakness Weight loss Cough Ringing in ears GI: Weight gain Joint pain Leg swelling Diarrhea Nausea/Vomiting Joint stiffness Joint swelling Pain Management Clinic Family First HealthCare of NEGA Musc/Skeletal: Neurology: Pain Management Clinic Leg cramps Headaches Muscle spasms Can’t sleep Memory loss Seizures Neurology: Tingling/Numbness Tremors Weakness in limbs, : difficulty, : walking difficulty, : loss of consciousness : Paralysis, : sensory disturbance, : rt/left arm leg Hematology: Abnormal bleeding Psychology: schizophrenia Anxiety Easy bruising Depression speech Enlarged nodes , : High stress level blood clot Anger bipolar, Urinary loss of bladder CONTROL, immediate need for urinate, having urinate at night Females: Males: Weak bladder Difficulty- urination Endocrine: sugar Sleep, : Post-Menopausal Difficulty- erections Excessive sweating snoring, : Diminished libido insomnia, : Easy Fatigue Diminished libido Thyroid problems low or high day time sleepiness , : fatigue Allergy: Itchy or red eyes Runny nose Skin itch/scratch Eye vision loss , blurred vision Comments: ______________________________________________________________________ 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 effect due to falsification or omission are responsibility of the patient. I verify that information in this form is accurate and complete. Name of patient _________________________________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Signature_______________________________________ Date _______________________________ 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 this 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 Pain 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 Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 _______________________ Date Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Authorization for collection, use, and release of Personal and Medical Confidential Information 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 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 firm 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. 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 disclosure by the recipient and may no longer protected. Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic 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 120313 Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Consent for Release of Information To give you the best possible care, 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: Family First Healthcare of NEGA, LLC (FFHC) 11973 Augusta Road Lavonia, GA 30553 Ph: 706-356-8181 Fax: 706-356-8081 Email: [email protected] Information to be released includes: Copies of History & Physical and Clinical Notes Copies of Laboratory and X-ray, and other diagnostic results Copies of Operative Reports and Discharge Summaries 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. ___________________________________ _____________________ Signature Date ___________________________________ _____________________ PRINT Name Date of Birth Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic 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 abovementioned Medications. Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Pain Management Patient Care Agreement I, ____________________________________ understand that in order to receive care for the treatment of pain at FFHC Pain Clinic, Lavonia, GA. 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 Clinic, Lavonia, GA. 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 Clinic, Lavonia, GA). 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 Clinic, Lavonia, GA. 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 Clinic, Lavonia, GA 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 Clinic, Lavonia, GA. E. DRUG SCREENING: I will participate in drug screening as a part of my treatment plan. I understand that drug screening will be conducted every month and may be required more frequently at the discretion of FFHC Pain Clinic, Lavonia, GA. 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 narcotic prescriptions is against clinic policy.Testing for alcohol use may be added to random and routine urine drug screens at the discretion of the physician. Any use of alcohol deemed inappropriate by the physician will be grounds for termination from FFHC Pain Clinic, Lavonia, GA. Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic G. ILLEGAL AND NON-PRESCRIBED DRUG USE: I understand that the use of any controlled medication, not prescribed by FFHC Pain Clinic, Lavonia, GA. may result in termination of care. I authorize FFHC Pain Clinic, Lavonia, GA 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 FFHC Pain Clinic. H. LOST OR STOLEN MEDICATION: I agree to safeguard all medication prescribed by FFHC Pain Clinic, Lavonia, GA and understand that lost, stolen, or damaged medications will not be replaced. All stolen medications 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 Clinic, Lavonia, GA 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 my home in Georgia, I need to advise FFHC Pain Clinic of the name and address of my provider out of state. I also authorize FFHC 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 FFHC Pain Clinic. L. CANCELLATIONS: As of October 1st, 2014; 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. 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 FFHC Pain Clinic. N. TERMINATION: I will no longer be eligible for care at FFHC Pain Clinic, Lavonia, GA if I am in possession of illicit drugs or substance, trafficking in controlled or illegal Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic 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, GA. I understand that this doctor may stop prescribing opioids or change the treatment plan if: 1. I do not show any improvement in pain from opioids or my physical activity has not improved. 2. My behavior is inconsistent with the responsibilities outlined in #1 above. 3. I develop rapid tolerance or loss of improvement from the treatment. 4. I obtain opioids from other than this doctor. 5. I refuse to cooperate when asked to get a drug screen. 6. If an addiction problem is identified as a result of prescribed treatment or any other addictive substance. 7. If I am unable to keep follow-up appointments 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 Pain 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 Clinic, Lavonia, GA 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 hospitalizations. 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: __________________ I HAVE THOROUGHLY READ THIS AGREEMENT BEFORE RECEIVING TREATMENT AT FFHC PAIN CLINIC, LAVONIA, GA. 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. Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Reviewed contract and answered all patients’ questions (MA): ________ Date: _____________ Patients’ Signature: ___________________________________________ Date: _____________ Practitioner Signature: _________________________________________ Date: _____________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic OPIOID RISK TOOL PATIENT FORM Name:__________________________________ Age:_________ Mark Each Box That Applies 1. Family History of Substance Abuse 2. Personal History of Substance Abuse • • • • • • Alcohol Illegal Drugs Prescription Drugs Alcohol Illegal Drugs Prescription Drugs Score If Female Score If Male 1 3 2 3 4 4 3 3 4 4 5 5 1 1 3 0 3. Age (Mark Box if 1645 years) 4. History of Preadolescence Sexual Abuse Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA 5. Psychological Disease Pain Management Clinic • • AttentionDeficit/Hyperacti vity Disorder; Obsessive Compulsive Disorder; Bipolar Disorder; Schizophrenia Depression 2 2 1 1 Total Score ________Risk Category_________ Low Risk 0-3 Moderate Risk 4-7 High Risk >7 Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic Follow-up Pain Questionnaire For data entry in EMR only. Not a part of medical record Name: ___________________________________________ Date: _________________ SINCE THE LAST visit at this clinic: 0 1 2 3 4 5 6 7 8 9 10 My WORST Pain score: |_____|_____|_____|_____|_____|_____|_____|_____|_____|_____| 0 1 2 3 4 5 6 7 8 9 10 My LEAST Pain score: |_____|_____|_____|_____|_____|_____|_____|_____|_____|_____| 0 1 2 3 4 5 6 7 8 9 10 My USUAL Pain score: |_____|_____|_____|_____|_____|_____|_____|_____|_____|_____| SINCE THE LAST visit at this clinic: Better Worse About the same My pain is: I am sleeping: Better Worse About the same I am functioning: Better Worse About the same Less More About the same My Medication use is: SINCE THE LAST VISIT at this clinic, I had: X-Rays CAT Scan MRI Scan Myelogram Nerve Testing (EMG) Bone Scan Injury Allergies Surgery Evaluation _____________________________ I am CURRENTLY taking the following for PAIN and PAIN RELATED issues: Name Pill strength Amount at a time How often? e.g: Advil 200 mgs 2 to 3 tablets 3 times a day ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ ___________________ ___________ _______________ _________________ SINCE THE LAST VISIT at this clinic: I have discontinued this medication (s): _____________________________________________________ I have started this medication(s): __________________________________________________________ Comments: ___________________________________________________________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Pain Management Clinic PLEASE ENTER INFORMATION ON BOTH SIDES OF THIS FORM LAST VISIT at this clinic, I have suffered from of the following: SINCE THE new numbness new weakness new pain dizziness diarrhea nervousness anxiety insomnia confusion tremors memory lapse flushing itching bladder problems lightheaded fatigue drowsiness double vision blurred vision constipation excessive sweating dry mouth swelling hallucinations headaches jerkiness nausea/vomiting recreational drug use breathing difficulty sleepiness/sedation _____________________ _____________________ Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Family First HealthCare of NEGA Family First Healthcare of NEGA, LLC 11973 Augusta Rd, Lavonia, GA Ph: 706-356-8181 Fax: 706-356-8081 Pain Management Clinic Pain Management Clinic
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