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