Locations: North Austin San Marcos Seguin 12414 Alderbrook Ste 101 Austin, TX 78758 512-498-1029 601 A Leah Ave. San Marcos, TX 78666 512-498-1029 205 N King St. Seguin, TX 78155 830-627-3800 New Braunfels San Antonio Killeen 213 Hunters Village New Braunfels, TX 78132 830-627-3800 4410 Medical Dr. Ste 390 San Antonio, TX 78229 210-614-9955 3202 S W.S. Young Ste. 102 Killeen, TX 76542 254-247-3322 Seguin Waco 515 N. King St. Ste 103 Seguin, TX 78155 830-627-3800 205 Woodhew Dr. Ste 203 Waco, TX 76712 254-732-6632 South Austin 4316 James Casey St. Bldg. B Ste.200 Austin, TX 78745 512-498-1029 Even though we at Central Texas Pain Center are committed to compassionate care, we must exercise proper due diligence when prescribing opioid analgesics for chronic pain. Prescription drug abuse has reached epidemic proportions in our society. Therefore, our clinic policy is that an appropriate workup must be completed prior to the dispensing of an opioid prescription. This workup will include review of previous pharmacy/clinic records, evaluation by diagnostic and laboratory tests, and acceptable completion of a urine drug screen yielding expected results. Common examples of opioid analgesics include hydrocodone, morphine, oxycodone, fentanyl, opana, and methadone. Prescriptions for these medications will not be given at an initial visit.  Please bring your driver’s license and insurance cards along with your completed new patient paperwork for your scheduled appointment. Payment for services are expected at the time of service (co-pays, co-insurance, private pay). We accept cash, check, money order, and credit cards (Visa, American Express, MasterCard, and Discover).  If you have been instructed to obtain imaging reports and/or films by our staff, please bring them to your appointment. Our office requires these as part of your consultation. If we do not have your films at the time of your appointment, you may be rescheduled.  Your initial visit at Central Texas Pain Center is a consultation. If a doctor referred you for an injection, you must be seen for an office visit. Procedures are scheduled after the initial consultation.  If English is your second language, please make arrangements for someone to accompany you to your visit who can translate in order to provide you with the best healthcare service. We want you to fully understand your diagnosis and prognosis, and have any questions you may have answered. We wish to make your visit as comfortable as possible, so please do not hesitate to contact us if you have any questions at the numbers listed above. NAME: ___________________________________________________ DATE OF BIRTH: __________________________ NEW PATIENT INTAKE NAME: __________________________________________________DATE OF BIRTH: __________________GENDER:____M____F ADDRESS: __________________________________________________________________________________________________ CITY: _____________________________________________________ STATE: __________________ ZIP: ____________________ HOME PHONE: _______________________CELL PHONE: _______________________WORK PHONE: ______________________ SSN: ____________________________________________DRIVERS LICENSE #:_________________________________________ ETHNICITY: □Hispanic or Latino RACE: □American Indian □Not Hispanic or Latino PREFERRED LANGUAGE: ____________________________ □Asian □Black or African American □Native Hawaiian or Other Pacific Islander □White □Other RELIGION: ______________________________________________ EDUCATION: __________________________________ EMAIL: ______________________________________________MARITAL STATUS: WHAT IS YOUR PREFERRED METHOD OF COMUNICATION? □Married □Widowed □Single □Divorced □Home phone □Cell Phone □Work Phone □E-Mail REFERRING PHYSICIAN: ______________________________PRIMARY CARE PHYSICIAN: _______________________________ OTHER PHYSICIANS: _________________________________________________________________________________________ EMERGENCY CONTACT: _______________________________________ RELATIONSHIP: ________________________________ EMERGENCY PHONE: _______________________________________ PHONE TYPE: ___________________________ RESPONSIBLE PARTY INFORMATION NAME: __________________________________________________________DATE OF BIRTH: _____________________________ ADDRESS: __________________________________________________________________________________________________ PHONE: _____________________________SSN:________________________________RELATIONSHIP:_____________________ EMPLOYER: ______________________________________________________EMPLOYER PHONE: _________________________ INSURANCE or ATTORNEY (if applicable) INFORMATION INSURANCE COMPANY: ________________________________________________ Please provide card to front desk. INSURED’S NAME: ________________________________________________DATE OF BIRTH: ____________________________ INSURED’S SSN: ____________________________________RELATIONSHIP TO PATIENT: □SELF □SPOUSE □DEPENDENT ATTORNEY NAME: _________________________________________ ATTORNEY PHONE: ___________________________ ATTORNEY ADDRESS: _______________________________________________________________________________________ NAME: ___________________________________________________ DATE OF BIRTH: __________________________ Clinic Policies Initials ________Payment is due at the time services are rendered. I understand that if I have insurance that I am the responsible party, and that having insurance does not guarantee payment of the services rendered to me. I authorize submission of my claim to the insurance company listed above. Initials ________If you are unable to make an appointment please call within 24 hours prior to your appointment time to reschedule. If you fail to notify our office prior to missing your scheduled appointment you will be charged a NO SHOW fee of $25 for an office visit and $50 for a procedure. Frequent NO SHOWS may result in a release from the practice. Initials ________Permission for treatment: I hereby authorize physician and assistants for the care of the patient named on this record to administer treatment as may be deemed necessary including examinations of treatments that may be ordered to be performed by the clinical personnel. I acknowledge that no guarantees have been made to me to the result of examinations or treatments to be performed. Acknowledgement of Review of Notice of Privacy Practices I have reviewed this office’s notice of privacy practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document. ______________________________________________ Signature of Patient or Representative ____________________________________________ Date ______________________________________________ Witness (CTPC Employee) ______________________________________________ Description of witness authority ***Please list the name of any person(s) you wish to have access to your medical information, including portal access: Name: ________________________________________Relationship:________________________ Name: ________________________________________Relationship:________________________ NAME: ___________________________________________________ DATE OF BIRTH: __________________________ Medication Contract The following outline is a medication contract between ____________ (patient) and the Central Texas Pain Center (CTPC) concerning the usage of opioid analgesics. Examples of opioid analgesics include hydrocodone, oxycodone, fentanyl, and morphine. Opioid analgesics may not completely relieve pain symptoms. If the doctors of CTPC feel that you are not responding to therapy by showing substantial improvement in function, your medications will be tapered. The following statements are relevant concerning opioid analgesics. 1) There are risks associated with chronic opioid therapy including but not limited to constipations, itching, addiction, physical dependence, sexual dysfunction, nausea, vomiting, and drowsiness. 2) CTPC recommends that ALL patients on chronic opioids not participate in the operation of motor vehicles or machinery. If the patient chooses to engage in these activities, CTPC bears no responsibility for the outcome of such events. 3) The patient will use only one pharmacy and will notify us with the name of the chosen pharmacy. 4) Unannounced urine drug screenings will happen during the course of treatment and you are expected to comply. Positive results of illicit drugs, excessive alcohol or negative results of the prescribed drug may result in termination from the clinic. In addition opioid analgesics will NOT be prescribed on your initial visit because an acceptable urine screen and review of pharmacy records must occur prior to starting these medications 5) Our clinic must be notified THREE BUSINESS DAYS prior to an anticipated refill date. 6) Lost or stolen medications will not be replaced for ANY REASON. In addition refills will not be given for any reason after hours or on weekends. Early refills will only be given if authorized by the physician or if a dosage is increased. 7) Patients will not seek opioid analgesic from any other physician for treatment of their chronic condition. This policy in no way prevents a patient from seeking acute care for acute problems. 8) If you are coming in for an early office visit, you will need to bring all unused opioids to your appointment The patient acknowledges that he/she has read this contract and agrees to abide by its regulations. ______________________ Patient signature ______________________ Date ____________________ CTPC representative NAME: ___________________________________________________ DATE OF BIRTH: __________________________ PAST MEDICAL HISTORY: Please indicate if you have suffered any of the following medical conditions. Also, state the year when these occurred. _____AIDS or HIV _____Arthritis _____Asthma _____Cancer _____Chronic skin disease _____Depression _____Diabetes _____Emphysema _____Fibromyalgia _____Gall bladder _____Gonorrhea _____Gout _____Headaches/migraines _____Heart disease/attack _____Heart failure _____Heart murmur _____Hepatitis _____Herpes infection _____High blood pressure _____Hormone problems _____Insomnia _____Irregular heart beats _____Jaundice _____Kidney disease _____Kidney stones _____Liver disease _____Lupus _____Menopause _____Multiple sclerosis _____Nervous breakdown _____Other blood abnormality _____Other venereal disease _____Panic attacks _____Peptic ulcer disease _____Peripheral vascular disease _____Pneumonia _____Prostate enlargement _____Rheumatic heart _____Schizophrenia/bipolar _____Seizures/convulsions _____Shingles _____Stroke _____Syphilis _____Thyroid _____Tuberculosis _____Urinary infection _____Other:________________________ __________________________________ __________________________________ PAST SURGICAL HISTORY  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________ FAMILY HISTORY: Please list any disease, illness, or ailments in your IMMEDIATE FAMILY (i.e. mother-breast cancer, father- diabetic, grandfather-heart disease).  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________  ____________________________________________________________________________________________________ NAME: ___________________________________________________ DATE OF BIRTH: __________________________ SOCIAL HISTORY OCCUPATION: ______________________________________________________________ □Yes □No HOW MANY PACK(S) DAY? _______ DRINK ALCOHOL? □Yes □No IF YES HOW MUCH? _________________________ DO YOU SMOKE? YEARS? ______ DO YOU USE ANY OTHER DRUG (Marijuana, Cocaine, etc.)? □Yes □No If yes, which drug? _______________ MARITAL STATUS? □Single DO YOU LIVE ALONE? □Yes □Married □Divorced □Widowed □No If no, who do you live with? _______________ ALLERGIES ______________________________________________________________ PHARMACY NAME AND LOCATION _____________________________________ CURRENT MEDICATIONS ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ REVIEW OF SYSTEMSYSTEMS: In the past few months, have you had any of the following symptoms or difficulties? If you have any difficulty that bears further explanation, please indicate so and explain in the additional notes section. GENERAL: Loss of appetite ……………… � YES Fever or chills …………………. � YES � NO � NO Recent weight loss ………………..…� YES Low energy/Fatigue …………………� YES � NO � NO EYES: Blurred vision…………………… � YES Loss of vision…………………… � YES � NO � NO Double vision…………………………� YES Eye Pain……………………………….� YES � NO � NO HEAD/EARS/NOSE/THROAT: Hoarseness……………………… � YES Trouble swallowing………….….. � YES � NO � NO Hearing loss……………………...……� YES Ear pain…….…………………..….… � YES � NO � NO NAME: ___________________________________________________ DATE OF BIRTH: __________________________ CARDIOVASCULAR: Chest pain……………………..… � YES Leg Swelling…………………..… � YES Varicose Veins……………….…. □ YES � NO � NO □NO Palpitations………………………...….� YES Orthopnea…………………….………..� YES � NO � NO RESPIRATORY: Shortness of breath ………….....� YES Wheezing………………...……….� YES � NO � NO Chronic cough ………………..……...� YES � NO GASTROINTESTINAL: Nausea or vomiting…………..…..� YES Blood in stool……………….……..� YES Change in bowel habits……..……□YES � NO � NO □NO Heartburn…………….….…..………..� YES Constipation…………….…..……….. �YES Hemorrhoids……………….…………□YES � NO � NO □ NO KIDNEY/BLADDER/URINE: Painful urination……………..…….� YES Frequent Urination..……………....� YES � NO � NO Blood in urine………………………..�YES Change in urinary pattern……….….□YES � NO □NO MUSCULOSKELETAL: Significant pain/stiffness…………□ YES □ NO SKIN: Rash………………………….……..� YES Frequent Rashes……………….....� YES � NO � NO Itching………………………...………� YES � NO NEUROLOGICAL Tremor………………………………� YES Seizures………………………...…..� YES � NO � NO Dizziness………………………......…� YES Tingling………………………………..� YES � NO � NO PSYCHIATRIC: Depression………………………....� YES Drug/Alcohol addiction…….….….� YES Difficulty with sexual activities..…. □YES �NO �NO □NO Suicidal Thoughts……………….…….� YES Trouble sleeping (Insomnia)……...….� YES � NO � NO ENDOCRINE: Thyroid disease……………….……� YES �NO Heat/Cold intolerance……………..….� YES � NO HEMATOLOGICAL/LYMPHATIC: Easy bruising…………………..…..� YES �NO Easy bleeding………….……….……..� YES � NO IMMUNOLOGIC: Enlarged/ swollen lymph glands…□ YES □NO ADDITIONAL NOTES ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ NAME: ___________________________________________________ DATE OF BIRTH: __________________________ Pain Evaluation Is there an ongoing lawsuit related to your visit today? � YES � NO Are you currently under worker’s compensation? � NO � YES Location of your pain: __________________________________________ When did it start? _____________________________________________ What happened and when? (car accident, fall, nothing, etc.) ________________________________________________________________________________________ __________________________________________________________________________________ From scale of 0 to 10 (0=no pain and 10= severe pain) how bad is your pain today? _______ over the past 30 days what was your average pain score? __________ What aggravates your pain? (Circle all that apply) Sitting Bending Walking Lying down Leaning forward Leaning back Coughing/sneezing Climbing upstairs Going downstairs Stretching Rest Heat Cold Medication What makes your pain better? (Circle all that apply) Sitting Bending Walking Lying down Leaning forward Leaning back Coughing/sneezing Climbing upstairs Going downstairs If medication, which ones? ___________________________________________________________________________ What treatments have you tried in the past? When did you have these treatments? Did it Treatments Tried (yes or no) When (year) Chiropractor ______________ ______________ Traction ______________ ______________ Braces ______________ ______________ Nerve Block ______________ ______________ Physical Therapy ______________ ______________ Hypnosis ______________ ______________ Acupuncture ______________ ______________ Biofeedback ______________ ______________ Ice/heat Pack ______________ ______________ Narcotics ______________ ______________ Massage ______________ ______________ Religious Counseling ______________ ______________ Psychological Counseling ______________ ______________ TENS/ Electrical Stimulation ______________ ______________ Pain Medication ______________ ______________ Surgery ______________ ______________ help? (Indicate below) Helped (yes or no) ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ If you have had surgery for the pain, please list what kind, how many, when, and if it helped: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Which treatment above has helped you the most? _________________________________________________________ NAME: ___________________________________________________ DATE OF BIRTH: __________________________ Using the appropriate symbol, mark the area(s) on your body where you feel each of the sensations above. Numbness Pins & Needles Burning Aching Stabbing ---------------- o o o o o o o o ^^^^^^ XXXXXXX ΦΦΦΦΦΦ Constant Intermittent Deep Superficial ccccccc iiiiiiiiiiiiiiiii ddddd sssssssssss How long can you be comfortable until pain increases? Sitting 0 min 1-30 min 31-60 min 1 hour Standing 0 min 1-30 min 31-60 min 1 hour Resting or reclining 0 min 1-30 min 31-60 min 1 hour How much time do you spend each day….? Sitting Less than 2 hrs 2-5 hrs 5-8 hrs 8-12 hrs 12 hrs Standing or walking Less than 2 hrs 2-5 hrs 5-8 hrs 8-12 hrs 12 hrs