Download ADVANCED INTERVENTIONAL PAIN CONSULTANTS Initial

ADVANCED INTERVENTIONAL PAIN CONSULTANTS
Name _______________________________
Initial Consultation
Date of Birth _____________
Age _____
PRIMARY CARE DOCTOR ___________________ REFERRING PHYSICIAN _______________________
What is your MAIN PAIN COMPLAINT?
Back
Neck
Joint
Muscles Headaches Other ________________________
HISTORY OF PRESENT ILLNESS
When did the pain start?__________________________
Where you involved in a motor vehicle accident? ___ Yes___ No___ Did you sustain a work related injury? ___Yes ___ No
How did the pain start? ____________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Where is your pain located?
Draw in the diagram where your pain is located
How intense is your pain?
Circle the lowest and highest levels
How do you best describe your pain?
___ Aching ___ Electrical ___ Stabbing ___ Sharp
___ Dull ___Throbbing ___ Shock-like ___ Burning
What is the pattern of your pain?
___ Constant ___ Intermittent
___ Mornings ___ Afternoons ___ Nights
Does the pain radiate to other areas? ___Yes ___No
If yes, where? ______________________________
Any associated symptoms? ___ Numbness ___ Tingling ___ Weakness ___ Muscle spasms
What makes the pain worse? __________________________________________________________________________________
What makes the pain better? __________________________________________________________________________________
Overtime, is the pain getting? ___ Better ___ Worse ___ About the same
Fill this part only if you are being consulted for HEADACHES
Draw where you headaches are located
How many headaches do you have per month? _____
How long do headaches usually last? ____________________
Associated symptoms: ___Nausea ___Vomiting ___Dizziness
___Flashing lights ___Ringing in ears
When does your headaches occur? ______________________
Have you been evaluated by a Neurologist? ___ Yes ___ No
If yes, what is his name? _______________________________
List all medications you have tried for headaches in the past:
___________________________________________________
___________________________________________________
___________________________________________________
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What MEDICATIONS have you used in the past for pain relief?
Opioids
___ Morphine (Avinza, Kadian, MS Contin)
___ Oxycodone (Oxycontin, Percocet, Percodan, Endocet)
___ Codeine (Tylenol #3 or #4)
___ Hydrocodone (Vicodin, Norco, Vicoprofen, Lortab, Lorcet, Zohydro)
___ Tramadol (Ultram)
___ Hydromorphone (Dilaudid, Exalgo)
___ Oxymorphone (Opana)
___ Fentanyl (Duragesic, Fentora, Actiq)
___ Tapentadol (Nucynta)
___ Buprenorphine (Butrans, Subaxone, Subutex)
___ Methadone (Dolophine)
Anti-inflammatories
___ Ibuprofen (Motrin, Advil) ___Naproxen (Naprosyn, Anaprox, Naprelan, Aleve)
___ Meloxicam (Mobic) ___Piroxicam (Feldane) ___Celecoxib (Celebrex) ___Etodolac
___ Diclofenac (Voltaren) ___Nabumetone (Relafen)
Muscle relaxants
___ Carisoprodol (Soma), ___Baclofen, ___Cyclobenzaprine (Flexeril, Amrix)
___Metaxalone (Skelaxin), ___Tizanidine (Zanaflex), ___Methacabamol (Robaxin)
Anticonvulsants
___ Gabapentin (Neurontin), ___Pregabalin (Lyrica), ___Topiramate (Topamax)
___ Carbamazepine (Tegretol), ___Oxcarbazepine (Trileptal), ___Phenytoin (Dilatin)
___ Lamotrigine (Lamictal)
Antidepressants
___ Duloxetine (Cymbalta) ___Venalafaxine (Effexor) ___Desvenlafaxine (Prestiq),
___ Milnacipran (Savella) ___Amitriptyline (Elavil) ___Nortriptyline (Pamelor) ___Fluoxitine (Prozac)
___ Citalopram (Celexa) ___Sertraline (Zoloft) ___Trazadone (Desyrel) ___Mitarzipine (Remeron),
___ Bupropion (Wellbutrin)
Benzodiazepines
___ Alprazolam (Xanax) Lorazepam (Ativan) Diazepam (Valium) Clonazepam (Klonopin)
Sleep aids
___ Zolpidem (Ambien) Eszopiclone (Lunesta) ___ Zaleplon (Sonata) ___ Ramelteon (Rozeram)
Have you been treated by a pain management doctor(s) before? ___ No ___ Yes
List the doctor(s) name(s) and dates? ____________________________________________________
____________________________________________________
Have you had pain injections in the past?
___ No ___ Yes If yes, what type of injections and date of the injections?
____________________________________________________________
____________________________________________________________
Have you had a spinal cord stimulator trial? ___ No ___ Yes
If yes, when? __________________ Who performed the trial? _______________________________
Have you had a spinal cord stimulator permanently placed? ___ No ___ Yes
If yes, when? __________________ Who performed the placement?__________________________
Have you had a pain pump implanted? ___ No ___ Yes
If yes, when? __________________ Who performed the placement? __________________________
Have you been treated by a spine surgeon, neurosurgeon or orthopedic surgeon? ___ No ___ Yes
What is the name of the doctor(s) and dates? ______________________________________________
______________________________________________
______________________________________________
Have you had neck or back surgery? ___ No ___ Yes
What type of and dates of the surgery? ___________________________________________________
___________________________________________________
___________________________________________________
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OTHER TREATMENT MODALITIES
___ Exercise
___ Acupuncture
___ Massage
___ Hot packs
___ Cold packs
___ TENS units
___ Yoga
___ Holistic
___ Spiritual
___ Physical therapy
Standard
Aquatic
Traction
___ Chiropractor
___ Psychological
Counseling
Biofeedback
Cognitive
Date
Helped
No change
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HOW DOES PAIN AFFECT YOUR QUALITY OF LIFE?
Explain
___ Family life/marriage ____________________________________________________________________
___ Ability to work ________________________________________________________________________
___ Ability to sleep ________________________________________________________________________
___ Activities of daily living _________________________________________________________________
___ Sex life ______________________________________________________________________________
PAST SURGICAL HISTORY
List all past surgeries and dates
1) ________________________________________ 4) ________________________________________
2) ________________________________________ 5) ________________________________________
3) ________________________________________ 6) ________________________________________
PAST MEDICAL HISTORY
___ Heart disease ___ Congestive heart failure ___ Coronary artery disease ___ Heart attacks
___ Bypass surgery
___ Coronary stents
___ Hypertension _______________________________________________________________________
___ Stroke ___Transient ischemic attack_____________________________________________________
___ Diabetes ___________________________________________________________________________
___Thyroid disease ______________________________________________________________________
___ COPD ___ Asthma ___ Emphysema ___ Obstructive Sleep Apnea ___________________________
___ Liver disease ___ Cirrhosis ___ Hepatitis ________________________________________________
___ Seizures ____________________________________________________________________________
___ Cancer _____________________________________________________________________________
___ Fibromyalgia ___ Rheumatoid arthritis ___ Ankylosing Spondylitis ___ Lupus ___Psoriatic arthritis
___ Osteoarthritis ___ Osteoporosis ___ Fibromyalgia ________________________________________
___ Multiple sclerosis ____________________________________________________________________
___ Headaches _________________________________________________________________________
___ Depression ___ Anxiety ___ Bipolar disorder ____________________________________________
___ HIV Positive _________________________________________________________________________
___ Others ______________________________________________________________________________
Are you ALLERGIC or sensitive to any medications? ___ No ___ Yes List ___________________________________
________________________________________________________________________________________________
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List all MEDICATIONS FOR PAIN are you currently taking. Include dose, times per day taken, and name of prescribing doctor
1)
2)
3)
________________________________________________ 4) _______________________________________________
________________________________________________ 5) _______________________________________________
________________________________________________ 6) _______________________________________________
List all OTHER MEDICATIONS you are currently taking.
1)
2)
3)
4)
5)
Include dose and times per day taken
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
6) _______________________________________________
7) _______________________________________________
8) _______________________________________________
9) _______________________________________________
10) _______________________________________________
Do you take any blood thinners? ___ Plavix ___ Coumadin ___ Lovenox ___ Heparin ___ Aspirin ___ Digabatran (Vigabatin)
___ Apixoban (Elquis) ___ Rivaroxaban (Xarelto) ___ Edoxaban (Lixiana) ___ Alteplase (Aclilyse)
___ Ticlopidine (Ticlid)
SOCIAL HISTORY
Are you employed? ___ No ___Yes, what is your occupation? _______________________ Are you disabled? ___No ___Yes
Marital status:
___ Married ___ Single ___ Divorced ___ Separated
How many children do you have? ____
Do you drink?
___ No ___ Yes How many drinks per week? _________________________
Do you smoke?
___ No ___ Yes How many cigarettes or packs per day? ________________
Do you currently use or have ever used illicit drugs
___ No ___ Yes, which ones? ___________________________
Have you ever abused narcotics or prescription medications? ___ No ___ Yes, explain _______________________________
Are you under the care of a Psychiatrist or Psychologist?
___ No ___ Yes
If yes, what is the name of your Psychiatrist? ____________________________ Psychologist? _________________________
Describe any significant traumatic events in your life ____________________________________________________________
________________________________________________________________________________________________________
FAMILY HISTORY
Does anyone in your family have a history of back or neck pain, depression, anxiety, or substance abuse (alcohol or drugs)?
___ No ___ Yes If yes, explain ____________________________________________________________________________
________________________________________________________________________________________________________
REVIEW OF SYSTEMS
Circle all that apply
1. General
2. ENT
Weight gain or loss, unexplained hair loss, fever or chills, low energy, too sleepy, too tired
Eye pain, vision problems (blurred vision, loss of vision), hearing loss, swollen glands in neck, sore
throat/pain when swallowing, dental problems
Chest pain (sharp, crushing, or heaviness), heart racing (palpitations), fainting spells, shortness of breath,
swelling of legs (edema)
Shortness of breath, cough/coughing up blood
Increased appetite, decreased appetite, stomach pain, nausea/vomiting, diarrhea, constipation
Pain when passing water (urination), blood in urine, urinating more than usual (day and/or night), bladder
Infection, pain during sex, changes in sex drive (libido)
Limited motion of arms or leg, joint pain, swelling/redness, numbness, tingling, or weakness in arms or legs
Arm/leg weakness, new headaches, problems with memory or speech, tremors
Sadness, stress, anxious, seeing or hearing things, suicidal thoughts, feeling down, insomnia
Weight gain/loss, thirsty all the time, cannot stand temperature changes (heat/cold)
Swollen glands (armpits or groin)
Rash (palm of hands, sole of feet), changes in skin, sores or rash on skin
Hives/skin rashes, allergic reaction to foods
3. Cardiovascular
4. Respiratory
5. Gastrointestinal
6. Genitourinary
7. Musculoskeletal
8. Neurological
9. Psychiatric
10. Endocrine
11. Lymph
12. Skin
13. Allergies
SLEEP APNEA SURVEY
____ No problems
___ Excessive loud snoring ___ Gasping or choking for breath while sleeping ___ Tired after sleeping
___ Falling asleep and daytime tiredness ___ Witnessed respiratory pauses ___ Night time difficulties
___ Have high blood pressure
I attest that ALL information I have provided is accurate and factual, and I can provide supporting information.
Patient‘s Signature __________________________________
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PHYSICAL EXAM
VITAL SIGNS
HR ______ BP ____________ RR ______ Weight _________ Height _________ BMI _______
GENERAL
___ Alert ___ Somnolent ___ Calm
___ Distressed ___ Pain behavior ___Clear speech
___ Pupils are round and equal, patient used adequate respiratory efforts and pulses are present
MUSCULOSKELETAL
___ Cane ___ Walker ___ Wheelchair ___ Brace ___ Sling
Inspection: Area _____________________ ___ Asymmetry ___Scars ___Atrophy ___ Scoliosis deformity ___ Kyphosis deformity
___ Midline posterior lumbar/cervical scar(s) ___ Anterior abdominal scar ___ Anterior neck scar
Palpation: Tender or trigger point areas and/or muscle spasm
___ Masseters
___ Supraspinatus ___ Gluteus max
___ Splenius capiti ___ Infraspinatus ___ Gluteus med
___ Semispinalis ___ Rhomboid
___ Piriformis
___ Trapezius
___ Rhomboid
___ > 11/18 tender
___ Deltoid
___ Paraspinalis
points (FM)
ROM:
NEURO
Facet joints pain/positive facet joint loading test
___ C2-3 ___ T1-2 ___ T7-8
___ L1-2
___ C3-4 ___ T2-3 ___ T8-9
___ L2-3
___ C4-5 ___ T3-4 ___ T9-10 ___ L3-4
___ C5-6 ___ T4-5 ___ T10-11 ___ L4-5
___ C6-7 ___ T5-6 ___ T11-12 ___ L5-S1
___ C7-T1 ___ T6-7 ___ T12-L1
Painful areas
___ Supraorbital
___ Temporal
___ Occipital
___ AC Joint
___ Greater trochanter
___ Infrapatellar ___ IT Band
___ Suprapatellar ___ SIJ Pain
___Lumbar
___Cervical
___Thoracic
___Hip
___Shoulder
___Knee
___Ankle
___Elbow
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Flexion
___ Extension
___ Extension
___ Extension
___ Extension
___ Extension
___ Extension
___ Extension
___ Extension
___ Distraction
___ Thigh Thrust
___ Compression
___ Gaenslen
___ Faber
___ SIJ 3/5 Positive
___ Rotation ___ Lateral Bend
___ Rotation ___ Lateral Bend
___ Rotation ___ Lateral Bend
___ Patrick-Faber (Hip/SIJ) ___ Resisted Abd Release (GT bursa)
___ Abd ___ Add ___ Internal/External rotation ___ Drop Arm Test (RCT)
___ACL-PCL Drawer ___ MCL Test ___LCL Test ___ McMurray’s (meniscus)
___ Inversion ___Eversion
___ AAO x 4
___ CN 3-12 intact
___ Normal Gait
___ Cerebellar function test normal (nose-finger-nose)
___ Normal motor function (5/5) ___ Normal deep tendon reflexes (2/4) ___Normal sensory function
___Allodynia ___Hyperalgesia ___Edema ___Erythema ___Cyanosis ___Cold/warm ___Hair pattern ___Skin
___ Abnormal motor function Right
Arm flexion/deltoid abd (C5) ___/5
Writs extension (C6)
___/5
Arm extension (C7)
___/5
Hand grip (C8)
___/5
Hip flexion (L2, 3)
___/5
Knee extension (L4)
___/5
Ankle dorsiflexion (L5)
___/5
Ankle plantar flexion (S1)
___/5
Left
___/5
___/5
___/5
___/5
___/5
___/5
___/5
___/5
___ Abnormal deep tendon reflexes
Biceps (C5)
___/4
Brachioradialis (C6)
___/4
Triceps (C7)
___/4
Patellar (L4, 5)
___/4
Achilles (S1)
___/4
___/4
___/4
___/4
___/4
___/4
___ Decrease light touch/pin prick sensation
___ Cervical axial loading test (disc)
___ Lumbar axial loading test (disc)
___ SLR Right Left
___Spurling Right Left
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MEDICAL RECORDS: ___ Reviewed ___ Not Available
MRI: Date ________
_ Reviewed
XRAY: Date ________ ___Reviewed
CT SCAN: Date ________ ___Reviewed
EMG: Date _________ ___ Reviewed
Inclinometry and muscle strength test: ___ Done today ___ Reviewed
SOAAP-R Score:
____
PMQ-R Score:
____
DEPRESSION Score: ____
DPS Report:
____ Reviewed
SLEEP APNEA Survey: ____ Done
ASESSEMENT:
LUMBAR
___ Lumbalgia
___ Facet arthralgia/arthritis
___ Spondylosis
___ DDD
___ HNP
___ Radiculopathy
___ Stenosis
___ Pseudoclaudication
___ Listhesis
___ Scoliosis
___ FBSS
___ Compression fracture
___ Foraminal stenosis
CERVICAL
___ Cervicalgia
___ Facet arthralgia/arthritis
___ Spondylosis
___ DDD
___ HNP
___ Radiculopathy
___ Stenosis
___ Listhesis
___ Kyphosis
___ FBSS
___ Foraminal stenosis
THORACIC
___ Thoracalgia
___ Facet arthralgia/arthritis
___ Spondylosis
___ DDD
___ HNP
___ Radiculopathy
___ Stenosis
___ Scoliosis
___ Kyphosis
___ Compression fracture
___ PTPS
___ PMPS
___ Costochonditits
HEAD
___ Cervicogenic Headaches
___ CDHA
___ Migraine
___ Occipital neuralgia
___ Supraobital neurlagia
___ Trigeminal neuralgia
___ Central pain
___ Seizures
___ CVA/TIA
___ TMJ syndrome
___ Atypical facial pain
_________________
PELVIS
___ Hip pain
___ Hip arthritis
___ Trochanteric bursitis
___ Piriformis syndrome
___ SIJ pain
___ Sacroilitis
___ SIJ dysfunction
___ Coccygodynia
___ Pelvic pain syndrome
___ Interstitial cystitis
___ Vulvodynia
___ Genital pain
___ Endometriosis
JOINTS
___ Shoulder pain
___ Shoulder arthritis
___ RC impingement
___ Rotator cuff strain
___ Rotator cuff tear
___ AC arthritis
___ SA bursitis
___ Knee pain
___ Knee arthritis
___ MCL LLC ACL/PCL
___ Meniscus tear (M/L)
___ Elbow pain/arthritis
___ Foot/ankle pain
___ Synovial bursa tendon
___ Hand/wrist arthritis
NERVES/MUSCLES
___ Fibromyalgia
___ Myofascial pain syd
___ Muscle spasms
___ CRPS arm
___ CRPS leg
___ Neuralgia/neuritis
___ Polyneuropathy idiopathic
___ DPN
___ PHN
___ Phantom pain syd
___ Neuroma
___ Paraplegia
___ Meralgia
___ Post-polio syd
___ Multiple sclerosis
___ CTS
CONNECTIVE
___ Osteoarthritis
___ Osteoposis
___ Rheumatoid arthritis
___ Psoriatic arthritis
___ Ankylosing Spondylitis
___ Sjogren’s
___ SLE
___ Enhlers Danlo’s syndrome
___ Raynaud’s
___ Enthesopathy
___ Plantar fasciitis
___ IT band pain/fasciitis
VARIOUS
___ Abdominal pain
___ Chronic pancreatitis
___ PAD
___ Ischemic pain
___ Adhesions
___ Post-surgical pain
___ Tumor pain
___ Kidney pain
___ Obstructive sleep apnea
PSYCH
___ Depression
___ Anxiety
___ Bipolar
___ PTSD
___ Alcohol dependence
___ Drug dependence
___ Drug withdrawal
___ Chronic pain syndrome
___ Insomnia
___ Drug abuse/misuse
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TREATMENT PLAN:
1. ___Pharmacologic therapy: ___ Medication’s risks, side effects and benefits were discussed with patient.
OPIOIDS Post date _________________ Refills ___
Tylenol 3 4 1 ______ # ____
Tramadol 50 mg 1 ______ # ____
Oxycodone 5 10 15 30 mg 1 ______ # ____
Opana 5 10 mg 1 ______ # ____
Hydromorphone 2 4 8 mg 1 ______ # ____
Tapentadol 50 75 100 mg 1 q6 hrs # ____
Morphine IR 15 30 mg 1 ______ # ____
Hydrocodone 5 7.5 10 mg 1 ______ # ____
APAP 325
Butrans 5 10 15 20 mcg/hr 1 q 7 days # ____
Ultram ER 100 200 mg 1 qd # ____
Oxycontin 10 15 20 30 40 60 mg 1 q8 q12 hrs # ____
Opana ER 5 7.5 10 15 20 30 40 mg 1 q12 hrs #
Exalgo 8 12 16 32 mg 1 ____ qd # ____
Morphine ER 15 30 60 mg 1 q8 q12hrs # ____
Nucynta ER 100 150 200 250 mg 1 q12 hrs # ____
Zohydro 10 15 20 30 40 50 mg 1 q12 hrs # ____
Methadone 5 10 mg 1 q12 q8 q6 hrs # ____
Fentanyl 12 25 50 75 100 mcg/hr 1 q72 q48 hrs # ____
Kadian 20 30 50 60 80 100 200 mg 1 q12 hrs # ____
Avinza 30 45 60 75 90 120 mg 1 qd # ____
MUSCLE RELAXANTS PRN MUSCLE SPASM Refills ____
Tizanidine 2 4 6 mg 1 qHS bid tid
# ____
Flexeril 5 10 mg 1 qHS bid tid
# ____
Soma 250 350 mg 1
qHS bid tid qid # ____
Baclofen 10 20 mg ½ 1 tid
# ____
Methocarbamol 500 750 mg 1 tid qid
# ____
ANTI-CONVULSANTS Refills ____
Lyrica 25 50 75 100 mg 1 qHS bid tid # ____
Neurontin 100 300 400 600 800 mg 1 qHS bid tid qid # ___
ANTI-INFLAMMATORIES Refills ____
Ibuprofen 800 mg 1 q8 hrs # ____
Meloxicam 7.5 15 mg 1 qd bid # ____
ANXIOLYTICS PRN ANXIETY Refills ____
Alprazolam 0.25 0.5 1 2 mg 1 qd bid tid # ____
Clonazepam 0.5 1 2 mg ½ 1 bid # ____
TOPICAL Anti-inflammatory Neuropathic
ANTI-DEPRESSANTS Refills ____
Cymbalta 20 30 60 mg 1 qd bid # ____ Refills ____
_________________ mg 1 qd bid # ____ Refills ____
Combination apply 1-2 gms to affected areas 120 240 gm 5 refills
Lidodem 5 % Patches apply 1 2 to affected areas q12 hrs on/12 hrs off # ____
2. ___ Interventional pain procedures:
1) _____________________________________
2) _____________________________________
3) _____________________________________
4) _____________________________________
7. ___ Psychological testing
SOAAP-R
PMQ-R Depression
3. ___ Physical therapy:
___ Land ___ Aquatic ___ Home Health
___ times per week for ___ weeks
9. ___ Psychological Evaluation:
___ Spinal cord stimulator trial
___ Suitability for chronic opioid use
___ Counseling ___ Biofeedback
4. ___ Imaging:
___ MRI
___ XRAY
___ CT SCAN
___ Myelogram
___ Bone scan
___ Lumbar
___ Cervical
___ Thoracic
___ Hip
___ Pelvis
___ Knee
___ Shoulder
5. ___ EMG/NCS: Dr. Al Baeer Dr. Nammour Dr. Yasser
___ Upper ___ Lower extremities
6. ___ Urine drug testing: Today
Next visit
___ As per PMQ protocol ___ Every visit
BBHI2
8. ___ Inclinometry and Muscle Strength Testing
___ Today
Every ____ months
10.___ Referral for consultation
Dr. _________________________________
Reason ______________________________
11. ___ Sleep Study. Diagnosis: OSA
12. ___ Run DPS report
13. ___ Follow up ___ month(s) ___ week(s)
___ Review UDT
___ Med refill
___ Review imaging
___ Post procedure(s)
___ Obtain patient’s medical records
The treatment goals ___ pain relief ___restore or improve function _______________________________________________
The expected length of treatment is _______________________________
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Based on the information obtained during the initial evaluation of this patient, it is my best clinical judgment to diagnose this patient with
___ Chronic Pain as defined by the TMB Rules Chapter 170, a state in which pain persists beyond the usual course
of an acute disease or healing of an injury. Chronic pain may be associated with a chronic pathological process.
___Intractable Pain as defined in the Texas Intractable Pain Treatment Act
___ the pain generator has been identified and cannot be removed or otherwise treated.
___ relief or cure of the pain generator is not possible
___ relief or cure of the pain generator has not been identified after reasonable efforts.
The information used in this determination includes some or all of the following items: The medical history and the
physical exam, review of past medical records available, review of previous diagnostic exams and therapeutic interventions
(surgeries, medications, interventional pain procedures, psychological treatments).
___ Treatment plan and the risks and benefits involving the use of all medications have been explained and discussed with the patient.
The patient signed medication contract/agreement and all questions have been answered. The patient understands that the use of
multiple treatment modalities is best when treating chronic pain conditions, and includes physical therapy, interventional pain
treatment, psychological and psychiatric consultation, nutrition, weight control and/or complementary and alternative medicine. The
patient agrees to the plan presented and will adhere to it. All alternative treatment options were discussed.
Level of service NEW VISIT CONSULT
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_____________________________ Jaime Robledo, M.D.
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