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Patient forms

WELCOME TO OUR OFFICE
Name: ____________________________________________________________ Date of Birth: ______________________________________ Address: __________________________________________________________ City: ______________________ State: ________ Zip Code: ________ Phone Number: ____________________________________________________ Social Security Number: ______________________________ Sex: [ ] M [ ] F Occupation: _____________________________________________________ Employer: __________________________________________________ Work Phone Number: ___________________________ Extension: ________ Cell Phone Number: __________________________________________
Primary Care Physician: ______________________________________________ Phone #: __________________________________________
Primary Care Physician’s Address: ______________________________________ City: ____________________ State: _________ Zip Code: ________
Referring Physician: _________________________________________________ Phone #: ___________________________________________
Referring Physician’s Address: _________________________________________ City: ____________________ State: _________ Zip Code: _______
EMERGENCY CONTACT

Name: ___________________________________________________________ Home Phone #: ______________________________________________
Relationship: ______________________________________________________ Work Phone#: _______________________________________________
PHARMACY INFORMATION

Pharmacy Name: ____________________________________________________ Pharmacy Phone #: __________________________________
Pharmacy Address: __________________________________________________ City: ______________________ State: __________ Zip Code: ________
IF THIS IS RELATED TO A MOTOR VEHICLE ACCIDENT OR WORKER’S COMPENSATION PLEASE FILL OUT THIS SECTION

[ ] MVA Related
Adjuster: _______________________________________________________ Phone Number: __________________________ Extension: _________ Billing Address: __________________________________________________ City: ________________________ State: __________ Zip Code:______
Claim Number: ___________________________________________________ Date of Incident: ____________________________________
PRIMARY INSURANCE

Insurance Company: _________________________________________________ Subscriber’s Name: __________________________________________
Subscriber’s Date of Birth: ____________________________________________ Subscriber’s Social Security #:__________________________________
Relationship: [ ] Self [ ] Husband/Wife [ ] Father/Mother [ ] Other ___________________________
SECONDARY INSURANCE

Insurance Company: _________________________________________________ Subscriber’s Name: __________________________________________
Subscriber’s Date of Birth: ____________________________________________ Subscriber’s Social Security #:__________________________________
Relationship: [ ] Self [ ] Husband/Wife [ ] Father/Mother [ ] Other ___________________________
RELEASE OF INFORMATION/ASSIGNMENT OF BENEFITS:

Authorization is hereby granted to release information as may be necessary to process and complete my claims. I hereby authorize payment of
medical benefits to be paid directly to the attending physician for services rendered.
_______________________________________________________________
___________________________________________________________ Center for Pain Management and Rehabilitation
635 East Main Street, Bridgewater NJ 08807
Phone: (908) 231-1131 Fax: (908) 231-1132

Shade in painful areas in the diagram below. (Please circle the most painful area)

FOR PHYSICIAN’S USE ONLY—DO NOT WRITE BELOW THIS LINE
Allergy: Intensity: 1 2 3 4 5 6 7 8 9 10 out of 10 Current Description of Pain: Location: Aggravating: Alleviating: Weakness/Numbness: Bowel/Bladder: Current Medications: Physical Exam: BP: ROM: Neurological Exam: Impression: Plan: Center for Pain Management and Rehabilitation
635 East Main Street, Bridgewater NJ 08807
Phone: (908) 231-1131 Fax (908) 231-1132

Previous Medications (Check appropriate boxes below if you have used these types of medications for your current pain problem and circle the
medications that you have used)
[ ] Narcotics (i.e., Demerol, Morphine, Dilaudid, MS Contin, Methadone, Darvon, Percocet, Talwin, Vicodin, Codeine,
[ ] NSAIDS (i.e., Aspirin, Motrin, Ibuprophen, Dolobid, Toradol, Advil, Naprosyn, Relafen, Orudis)
[ ] Sedatives / Relaxants (i.e., Ativan, Xanax, Valium, Librium, Flexeril, Parafon Forte)
[ ] Antidepressants (i.e., Elavil, Pamelor, Desipramine, Effexor, Desyrel, Prozac, Zoloft, Paxil, Serzone, Remeron)
[ ] Anticonvulsants (i.e., Neuronton, Klonipin, Tegretol, Dilantin)
[ ] Neuropathic Pain Medications (i.e., Baclofen, Mexitil, Phenoybenzamine, Ultram, Prazocin)
Previous Treatments (Please circle all that apply)
Other (specify) ________________________ Duration of Physical Therapy: ____________________________________ Review of Symptoms (Please circle all that apply)
Past Medical History (Please circle all that apply)

This page reviewed by attending physician.


Center for Pain Management and Rehabilitation
635 East Main Street, Bridgewater NJ 08807
Phone: (908) 231-1131 Fax: (908) 231-1132

Past Surgical History (Please indicate date, type of surgery and physician’s name)
_________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Medications (Please fill out all medications that you are using at this time)
How many times/day
Date Started

1.______________________________ ____________________ ____________________ __________________
2.______________________________ ____________________ ____________________ __________________
3.______________________________ ____________________ ____________________ __________________
4.______________________________ ____________________ ____________________ __________________
5.______________________________ ____________________ ____________________ __________________
6.______________________________ ____________________ ____________________ __________________
7.______________________________ ____________________ ____________________ __________________
8.______________________________ ____________________ ____________________ __________________
9.______________________________ ____________________ ____________________ __________________
10______________________________ ____________________ ____________________ __________________
This page reviewed by attending physician.


Center for Pain Management and Rehabilitation
635 East Main Street, Bridgewater NJ 08807
Phone: (908) 231-1131 Fax: (908) 231-1132

Social History (Please complete information below)

[ ]Remarried [ ] Divorced [ ] Separated [ ] Widowed Litigation history: is there any litigation in progress in regard to your pain condition? [ ] Yes Family History
FOR PHYSICIAN’S USE ONLY—DO NOT WRITE BELOW THIS LINE.
Miscellaneous __________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ This page reviewed by attending physician.

Source: http://www.njpainrehab.com/Patient%20Forms.pdf

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