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Pain Management Pt. Pack.docx - Skyview Medical Center

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Pain Management Pt. Pack.docx - Skyview Medical Center Powered By Docstoc
					                                  SKYVIEW MEDICAL CENTER
                                              11653 Chapman Highway
                                                Seymour, TN 37865
                                               Phone: (865)-773-0327
                                                Fax: (865)-773-0339

  THIS INFORMATION IS VERY IMPORTANT. PLEASE MAKE SURE THAT YOU KEEP THIS PAGE
                      BECAUSE THESE ARE YOUR INSTRUCTIONS.

By receiving this packet, you are initiating the process of becoming a patient of Skyview Medical Center. Completing this
information and going through the required interviewing process DOES NOT guarantee that you will be accepted as a
patient of Skyview Medical Center.

We believe in quality pain management. This may include ordering tests, procedures, doing psychological assessment,
and an exercise regimen.

Please be aware that all of our patients are called in for random drug screens and medication counts.
KEEP THIS PAGE SO YOU CAN REMEMBER WHAT TO BRING WITH YOU TO YOUR INTERVIEW OR FIRST VISIT.
This is a checklist for everything you need to do when you bring this packet back to us.

                         Be sure to complete every line, if it is not applicable, indicate with a N / A
                               Bring a copy of your valid TENNESSEE photo identification
                             Bring a copy of the front and back of your insurance card(s)
                      You must make a nonrefundable deposit of $100.00 when returning application
                       You will need to be prepared to have a witnessed urine analysis drug screen
                                    We will also obtain a criminal background check
                         Bring ALL MEDICATIONS YOU TAKE IN THEIR APPROPRIATE BOTTLES


   YOUR ACCEPTANCE AS A PATIENT AT SKYVIEW MEDICAL CENTER WILL BE DEPENDANT UPON YOUR
MEDICAL CONDITION AND DIAGNOSIS, LAB RESULTS AND BACKGROUND REPORT. A DETERMINATION WILL
 BE MADE WITHIN 2 TO 4 BUSINESS DAYS. PLEASE DO NOT CONTACT THIS OFFICE FOR RESULTS. WE WILL
  NOTIFY YOU BY VERIFYING WHETHER OR NOT YOU WILL BE ACCEPTED AS A PATIENT AT THIS FACILITY.



             PLEASE DO NOT BRING CHILDREN WITH YOU TO YOUR APPOINTMENT AS THE WAIT MAY BE LONG




      ***IF YOU FAIL TO FOLLOW THE CHECKLISTS WE MAY NOT BE ABLE TO SEE YOU***


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Today’s Date____/____/______                         Social Security Number_____/____/_______
LAST NAME                         FIRST NAME                        MIDDLE


STREET ADDRESS                    CITY/STATE                        ZIP CODE


HOME PHONE                        MOBILE PHONE                      EMAIL


DATE OF BIRTH                     AGE                               SEX
                                                                            MALE [ ]   FEMALE [ ]

HEIGHT                            WEIGHT                            DOMINANT HAND
                                                                         RIGHT [ ]     LEFT [ ]



EMPLOYER NAME                                                       WORK PHONE




EMERGENCY CONTACT NAME                                              CONTACT PHONE

EMERGENCY CONTACT RELATIONSHIP                                      CONTACT WORK PHONE




PHARMACY (1)                                                        PHONE

PAHRMACY (2)                                                        PHONE

                               How did you hear about us

[ ] Newspaper [ ] Internet [ ] Yellow Pages [ ] Other _______________________________________________

Patient Referral: Referred by: _________________________________________________________________

                               Past healthcare providers
Who is your Primary Care Provider? ____________________________________________________________



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                     Chiropractor? ____________________________________________________________

              Orthopedic Surgeon? ____________________________________________________________

                   Neurosurgeon? ____________________________________________________________

                   Rheumatologist? ___________________________________________________________

                       Neurologist? ___________________________________________________________

                            PM&R? ___________________________________________________________

                       Psychiatrist? ___________________________________________________________

                      Psychologist? ___________________________________________________________

                 Physical Therapist? ___________________________________________________________

Please list all imaging centers you have used (mri, xray, cat scans): ____________________________________

__________________________________________________________________________________________

                                       Pharmacy History
Please list all pharmacies you have used in the last six (6) months: ____________________________________

__________________________________________________________________________________________

List all pharmacies in Florida you have used: ______________________________________________________

__________________________________________________________________________________________

List all pharmacies in Georgia you have used: _____________________________________________________

__________________________________________________________________________________________

List any clinics you have used and filled in-house: __________________________________________________

__________________________________________________________________________________________

List any online pharmacies you have used: _______________________________________________________

__________________________________________________________________________________________



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Will you be using a different pharmacy to fill medications from other providers? If yes, please list: __________

__________________________________________________________________________________________

Please list any person(s) who will be authorized to receive your prescriptions:

Name: _________________________________                                Relationship: __________________________

Name: _________________________________                                Relationship: __________________________

                                               Pain History
Do you have more than one area of pain?          Yes [ ]      No [ ]                        If yes, please list below.

1) _______________________________________________________________________________________

2) _______________________________________________________________________________________

3) _______________________________________________________________________________________

How long ago did the pain begin? ______________________________                [ ] Weeks [ ] Months [ ] Years

What is your most pressing pain problem? _______________________________________________________

When did your pain become a daily problem? ____________________________________________________

Did your pain start suddenly? _________________________________________________________________

Describe the events leading up to your present pain complaints: Please include all accidents relating to your
pain (work, motor vehicle accidents, home, boating, etc.)___________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

When did the specific event(s) occur? ___________________________________________________________

If it was a car wreck, did the police work the wreck? [ ] Yes [ ] No          Did you receive a ticket? [ ] Yes [ ] No

Did you go to the Emergency Room at the time of the incident?                      [ ] Yes [ ] No

Did you seek medical care within 72 hours of the time of the event?                [ ] Yes [ ] No


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Did you have to spend more than 23 hours in the hospital?                                    [ ] Yes [ ] No

Did you miss work after the event?                                                           [ ] Yes [ ] No

Did you have to have surgery after the event?                                               [ ] Yes [ ] No

A lawsuit /personal injury claim /worker’s compensation claim as a result of the event? [ ] Yes [ ] No

If it was a work injury, was the incident filed under worker’s comp?                         [ ] Yes [ ] No

Did you have limited duty on the job after the injury?                                       [ ] Yes [ ] No

Has the lawsuit or worker’s comp claim been settled?                                        [ ] Yes [ ] No [ ] N/A

When did you begin pain management? _________________________________________________________

List all pain management facilities you have used in Tennessee: ______________________________________

In Florida: _______________________________________________ How long: _________________________

In Georgia: ______________________________________________ How long: _________________________

Any other out of state pain management facilities you have used: ____________________________________

________________________________________________________ How long: _________________________

What kind of services have you received form these facilities? _______________________________________

__________________________________________________________________________________________

If you have used an out of state pain management facility, please select one of the following reasons.

[ ] No insurance   [ ] Could not get a referral   [ ] Waiting list   [ ] Advertisement   [ ] TN MRI too expensive

[ ] Reputation of practice [ ] Friend/family [ ] Other ________________________________________________

                                            Patient History
Do you smoke?                        [ ] Yes [ ] No       If yes, how many packs daily? _____________________

Do you drink alcohol?                 [ ] Yes [ ] No      If yes, how often?_______________________________

Do you use any illegal drugs?         [ ] Yes [ ] No      If yes, what drugs do you use?____________________



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Have you ever been fired from a pain treatment program?                        [ ] Yes [ ] No

If yes, please explain_________________________________________________________________________

Have you ever been in a pain treatment program that closed?                    [ ] Yes [ ] No

Has a pain treatment program ever refused to accept you as a patient?          [ ] Yes [ ] No

Have you tried going for pain treatment closer to home?                        [ ] Yes [ ] No

Have you been prescribed pain medication from a family doctor or another non-pain management specialist?

                                                                               [ ] Yes [ ] No

Have you ever had pain medications prescribed to you over the internet?        [ ] Yes [ ] No

Have you been arrested for public intoxication?                                [ ] Yes [ ] No

Have you been arrested for DUI?                                                [ ] Yes [ ] No

Have you been arrested for drug possession?                                    [ ] Yes [ ] No

Have you ever been arrested for drug trafficking?                              [ ] Yes [ ] No

Have you ever been in drug court?                                              [ ] Yes [ ] No

Have you ever been in drug diversion program?                                  [ ] Yes [ ] No

Have you had any juvenile offenses?                                            [ ] Yes [ ] No

Have you had any misdemeanor arrests?                                         [ ] Yes [ ] No

Have you had any felony arrests?                                               [ ] Yes [ ] No

Have you served time in jail?                                                  [ ] Yes [ ] No

Are you on probation?                                                          [ ] Yes [ ] No

Are you on parole?                                                            [ ] Yes [ ] No

Have you bought medication or illegal drugs off the street?                   [ ] Yes [ ] No

Have you had problems running out of medication early?                        [ ] Yes [ ] No



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Have you ever failed an on-the-job drug screen?                             [ ] Yes [ ] No

Have you ever been to the Emergency Room for misuse or overdose?       [ ] Yes [ ] No

Have you ever been in detox?                                           [ ] Yes [ ] No

Have you ever been in an inpatient program?                            [ ] Yes [ ] No

Have you ever been in an outpatient program?                           [ ] Yes [ ] No

Have you ever been in a partial hospitalization program?               [ ] Yes [ ] No

Have you ever been in a faith based program?                           [ ] Yes [ ] No

Have you ever been in AA or self-help group?                           [ ] Yes [ ] No

Have you ever had court ordered treatment?                             [ ] Yes [ ] No

Have you ever been involved with a methadone clinic?                   [ ] Yes [ ] No

Have you ever lived in a half-way house?                               [ ] Yes [ ] No

Have you ever been a victim of child abuse?                            [ ] Yes [ ] No

Have you ever been a victim of sexual abuse?                           [ ] Yes [ ] No

Have you ever been a victim of verbal abuse?                          [ ] Yes [ ] No

Has your partner ever pushed or slapped you?                          [ ] Yes [ ] No

Has your partner ever thrown, broken or punched things?               [ ] Yes [ ] No

Has your partner ever threatened you with violence?                   [ ] Yes [ ] No

Have you ever tried to hurt yourself?                                 [ ] Yes [ ] No

Have you ever been treated for a psychiatric condition?               [ ] Yes [ ] No

Have you served (or serving) in a branch of the military?             [ ] Yes [ ] No

Branch: _______________________ Years Served: ________      Discharge Date: ______/______/_________

Were you in a combat theatre?                                         [ ] Yes [ ] No



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Were you injured during your military service?                               [ ] Yes [ ] No

Are you receiving VA benefits?                                               [ ] Yes [ ] No

Have you ever been arrested for a non-drug related misdemeanor?                [ ] Yes [ ] No

Have you ever been arrested for a non-drug related felony?                     [ ] Yes [ ] No

Have you ever been involved in an ADA/EEOC complaint?                          [ ] Yes [ ] No

Have you ever had a sports or recreational related injury?                     [ ] Yes [ ] No

Do you have any hearing problems?                                              [ ] Yes [ ] No

Has your weight been stable?                                                   [ ] Yes [ ] No

 Please list all medications you are taking right now for pain.
Name of Medication         Mg. / Tablets per Day        Helpful         Reason for stopping

_________________          ______/__________           Yes / No       ________________________________

_________________          ______/__________           Yes / No       ________________________________

_________________          ______/__________           Yes / No       ________________________________

Please list all medication allergies_______________________________________________________________

__________________________________________________________________________________________

Please list any vitamins, natural products or over the counter medications you use on a regular basis: _______

__________________________________________________________________________________________

Please list any medications you do not tolerate will: _______________________________________________

__________________________________________________________________________________________

Do you feel you have ever been overprescribed pain medications?                                 [ ] Yes [ ] No

What is the highest number of pills per day you have been prescribed? _________

What is the highest number of pain pills per day have you taken on your own? __________



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Any pain medications you are reluctant to use because you have heard bad things about them? [ ] Yes [ ] No

If yes, please list: ____________________________________________________________________________

           Circle any medications you have had experience with

      Amantadine               Dextromethorphan                Lamictal                      Talwin
     Amitryptaline              Dihydrocodiene                   Lyrica                    Tramadol
    Buprenorphine                    Effexor                  Methadone                      Valium
    Carbamazepine                   Fentanyl                  Morphine                    Valproic Acid
       Clonidine                  Guaifenesin                   Nubain                      Codiene
     Hydrocodone                    Nucynta                     Xanax                      Cymbalta
    Hydromorphone                 Oxycodone                    Xylocaine                    Darvocet
      Imipramine                     Savella                   Demerol                     Ketamine
        Stadol
    Rate on a scale (1-10) the three most effective medications

     Avinza _______             Codiene _______            Demerol _______            Dilaudid _______
    Fentanyl _______             Lortab _______           Methadone _______           Morphine _______
    Nucynta _______              Opana _______            Oxycontin _______          Roxicodone _______
   Suboxone _______             Ultram _______
                  Circle any medications you might recognize

  Roxicotten         Schoolboy               T-3             Tabs               Vikes        Yellow Footballs
      40           Blue Dynamite      Hillbilly Heroin      Hydros            Miss Emma         Ox Roxie’s
      80             Chine Wite            Dollies          Kicker             Morph               Oxy
    40-Bar             Cotton              Fizzies            M                   OC              Paulas
     512            Cough Syrup          Demmies             Pills                Os              Percs
       Please circle or list any past surgeries not on the list

    Adenoidectomy                Appendectomy               Cardiac Bypass               Cardiac Stent
       Cataract                   Colonoscopy              Cosmetic Surgery           Cryosurgery of Skin
                                                                                             Lesion
          EGD                   Dental Extraction             Gall Bladder          Exploratory Laparotomy
     Gastric Bypass              Hysterectomy              Joint Arthroscopy          Joint Replacement
       Lap Band                   Laparoscopy                  Lithotripsy            Open Reduction of
                                                                                           Fracture
     Pilonidal Cyst                  Sinus                     Prostate                  Spine Surgery
    Thyroidectomy                Tonsillectomy               Tubal Ligation              Tubes in Ears
    Vascular Bypass               Vasectomy


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Any surgeries not on list: _____________________________________________________________________

                                       Past medical conditions
      ADHD            Alcoholism              Allergies           Allodynia               Anemia               Angina
   Ankylosing         Spondylitis             Anxiety             Anorexia              Arrhythmia             Asthma
   Barotrauma         Bell’s Palsy        Bipolar Bleeding           BPH              Burning Mouth          CAD Cancer
  Carpal Tunnel       Cephalgia              Cervicalgia             CHF              Chronic Fatigue         Cirrhosis
Cluster Headache        Colitis             Colon Polyps        Compression                COPD                 CRPS
                                                                  Fracture
    Cystitis       Degenerative Disk         Dementia            Depression              Diabetes           Diverticulitis
  Dysethesias          Dystonia               Eczema            Emphysema              Endometriosis          Epilepsy
     Facet           Fibromyalgia           Gall Bladder            GERD                Heart Attack        Hemorrhoids
  Arthropathy
   Hepatitis        Herniated Disk          Herpetic            Hiatal Hernia         High Cholesterol           HIV
                                            Neuralgia
   HLA B27           Hypertension              IBS            Interstitial Cystitis   Kidney Stones           Kyphosis
   Lumbago              Lupus               Macular               Migraines           Modic Changes         Mood Disorder
                                          Degeneration
     MVP            Muscle Spasms         Myofascial Pain        Neuropathy               Obesity             Occipital
                                                                                                              Neuralgia
  Osteoporosis       Pancreatitis           Parathesias          Parkinson’s            Personality         Phantom Limb
                                                                    Disease              Disorder
 Pinched Nerve           PVD                Pneumonia              Psoriasis                RA              Radiculopathy
  Restless Leg       Rheumatism                RSD              Schizophrenia            Scoliosis            Shingles
    Seizures          Sjogren’s            Scheurman’s           Sleep Apnea           Spastic Colon             STD
                                             Disease
    Stenosis            Stroke           Substance Abuse            Syrinx              Tendonitis             Tension
                                                                                                              Headache
    Thyroid          Tic Doloreaux            Tinnitus                TMJ                 Ulcers               Venous
                                                                                                             Thrombosis
    Vertigo            Vitamin
                      Deficiency
  Circle the one that describes your course of health over time

Steady decline        No change          Remains stable          Waxes and            Remains stable     Getting better
                                         for a while then        wanes on a           for a while and
                                             drops off         frequent basis         then improves
                                           Review of Symptoms

   Allergies                         [ ] dusts [ ] foods [ ] insect stings [ ] latex [ ] molds [ ] pollen
    Blood                                     [ ] blood clots [ ] easy bruising [ ] free bladder

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    Cardiac            [ ] angina [ ] easily winded [ ] enlarged heart [ ] heart murmur [ ] irregular heartbeat
                              [ ] leaky heart valve [ ] mitral valve prolapse [ ] palpitations [ ] swelling feet
                                             [ ] sleep on more than 2 pillows [ ] use home oxygen
     Dental       [ ] bleeding gums [ ] braces [ ] bridge [ ] cavities [ ] dentures [ ] implants [ ] malocclusion
                           [ ] overbite [ ] plaque [ ] problems chewing [ ] receding gums [ ] sensitive teeth
                                                                  [ ] TMJ [ ] under bite
   Endocrine                 [ ] cold intolerance [ ] edema [ ] excess thirst [ ] excess urination [ ] fatigued
                            [ ] heat intolerance [ ] losing hair [ ] muscle weakness [ ] unable to lose weight
  Female GU           [ ] anorgasmia [ ] decreased libido [ ] dysmenorrhea [ ] hot flashes [ ] incontinence of
                         urine [ ] irregular periods [ ] menorrhagia [ ] midcycle pain [ ] miscarriage [ ] PMS
                                                         [ ] ovarian cysts [ ] vaginal discharge
Gastrointestinal       [ ] belching [ ] bloating [ ] bright red blood when wiping [ ] constipation [ ] cramping
                         [ ] diarrhea [ ] fatty food intolerant [ ] flatulence [ ] gluten intolerant [ ] heartburn
                    [ ] inconsistence of stool [ ] jaundice [ ] milk intolerant [ ] tarry stools [ ] vomiting blood
    Male GU           [ ] enlarged prostate [ ] slow urinary stream [ ] urinary hesitancy [ ] urethral discharge
                                    [ ] unable to get erection [ ] premature ejaculation [ ] scrotal masses
 Neurological         [ ] aphasia [ ] coma [ ] dementia [ ] headaches [ ] palsy [ ] seizures [ ] tics [ ] tremors
      Nose                [ ] congestion [ ] decreased sense of smell [ ] deviated septum [ ] nasal stuffiness
                             [ ] nosebleeds [ ] runny nose [ ] sinus drainage [ ] sinus pressure [ ] sneezing
  Psychiatric                   [ ] anxiety [ ] auditory hallucinations [ ] depression [ ] self- inflicted injury
                                                    [ ] suicidal ideation [ ] visual hallucinations
  Respiratory      [ ] air hunger [ ] can’t breathe deeply [ ] choking [ ] coughing up blood [ ] gurgling noises
                 [ ] labored breathing [ ] pleurisy [ ] productive cough [ ] short of breath [ ] smoker’s cough
                                                                 [ ] stridor [ ] wheezing
      Skin           [ ] age spots [ ] blackheads [ ] blisters [ ] boils [ ] burns [ ] dandruff [ ] dry skin [ ] easy
                 bruising [ ] fungal nails [ ] greasy skin [ ] hives [ ] itchy skin [ ] lipomas [ ] pattern baldness
                 [ ] pigment changes [ ] pimples [ ] rashes [ ] scars [ ] skin cancer [ ] spider veins [ ] tattoos
                                                      [ ] sun damage [ ] unexplained hair loss
                                              Family History
Is your mother alive? [ ] Yes [ ] No     Cause of death? _____________________________________________

Is your father still alive? [ ] Yes [ ] No Cause of death? _____________________________________________

    Please circle any health problem that may run in your family

Alcoholism       Anemia           Arthritis        Asthma           Back             Ulcers           Thyroid
                                                                    Problems
Bleeding         Cancer           Cirrhosis        Dementia         Depression       Kidney           Diabetes
Disorders                                                                            Stones
Diverticulitis   Drug Abuse       Emphysema        Skin             Obesity          Eye problems     Fibromyalgia
                                                   Problems
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Gout           Heart Attack    Migraines        Neuralgia      Stroke           Heart Failure   High Blood
                                                                                                Pressure
High Cholesterol   Mental Health
                   Problems
 Please circle all medical devices you have been advised to use

            AFO                     Crutches               Hard back brace                   Slings
      Diabetic Shoes                  Cane                    Knee brace                 Support pillows
    Elastic back brace         Carpal tunnel splint        Pedorthic device                TENS unit
   Exercise equipment            Cervical collar        Pressure relief mattress            Walker
      Foot supports            Compressions hose        Sequential compression             Wheelchair
                                                                devices
             Impact of activity (how does each make you feel)
          “W” = make pain worsen “N” = does not make a difference “L” = makes pain hurt less

             Bending                            W                        N                        L
               Lifting                          W                        N                        L
            Squatting                           W                        N                        L
             Kneeling                           W                        N                        L
             Twisting                           W                        N                        L
         Overhead reach                         W                        N                        L
             Pushing                            W                        N                        L
              Pulling                           W                        N                        L
             Jumping                            W                        N                        L
             Climbing                           W                        N                        L
            Lying flat                          W                        N                        L
               Sitting                          W                        N                        L
             Standing                           W                        N                        L
             Gripping                           W                        N                        L
             Walking                            W                        N                        L
              Jogging                           W                        N                        L
             Running                            W                        N                        L
          Going up stairs                       W                        N                        L
        Going down stairs                       W                        N                        L
              Resting                           W                        N                        L
           Taking a nap                         W                        N                        L
             Sleeping                           W                        N                        L
Does the change in climate affect your pain?                       [ ] Yes [ ] No



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                              SKYVIEW MEDICAL CENTER
If yes, please explain: ________________________________________________________________________

                                            Sleep history
What time do you usually get out of bed?             _____ : _____ am / pm

What time do you usually go to bed?                  _____ : _____ am / pm

How long does it take you to fall asleep? ________________________________________________________

How often do you wake up in the middle of the night? _____________________________________________

How long are you usually up before going back to sleep? ___________________________________________

How many times a week do you wake up early? ___________________________________________________

How many times a week do you wake up with a headache? _________________________________________

If you sleep poorly one night, do you make it up the next?                   [ ] Yes [ ] No

Do you snore?                                                                [ ] Yes [ ] No

Do you ever stop breathing while you are sleeping?                           [ ] Yes [ ] No

Do you wake up refreshed?                                                    [ ] Yes [ ] No

Have you ever had a sleep study?                                             [ ] Yes [ ] No

Do you ever feel like you just have to move your legs?                       [ ] Yes [ ] No

Do you ever have unpleasant crawly feelings in your legs?                    [ ] Yes [ ] No

Do these feelings occur mainly when you are resting?                         [ ] Yes [ ] No

Do these feelings improve with movement?                                     [ ] Yes [ ] No

Are these feelings worse at night rather than the daytime?                   [ ] Yes [ ] No

                                           Androgen status

                                                      MEN

Have you experienced a decrease in sex drive?                                [ ] Yes [ ] No



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                                SKYVIEW MEDICAL CENTER
Do you experience a lack of energy?                                                     [ ] Yes [ ] No

Has your strength and / or endurance decreased?                                         [ ] Yes [ ] No

Have you lost height?                                                                   [ ] Yes [ ] No

Have you noticed yourself enjoying life less?                                            [ ] Yes [ ] No

Are you frequently sad or irritable?                                                    [ ] Yes [ ] No

Has there been a recent deterioration in your work performance?                         [ ] Yes [ ] No

Have you noticed a recent deterioration in your athletic ability?                       [ ] Yes [ ] No

Do you find yourself falling asleep after dinner?                                       [ ] Yes [ ] No

Are your morning erections less strong or missing?                                      [ ] Yes [ ] No

                                                     WOMEN

Have you had a loss of energy and well-being?                                           [ ] Yes [ ] No

Have you had a decrease in your sexual desire?                                          [ ] Yes [ ] No

Have you had a loss of muscle tone?                                                     [ ] Yes [ ] No

Have you had new problems with urinary inconsistence?                                   [ ] Yes [ ] No

Do you have osteoporosis?                                                               [ ] Yes [ ] No

Have you noticed dry skin and brittle scalp hair?                                       [ ] Yes [ ] No

Have you noticed flatness of mood?                                                      [ ] Yes [ ] No

Have you noticed loss of mental sharpness?                                              [ ] Yes [ ] No

Have you noticed a thinning in pubic hair?                                              [ ] Yes [ ] No

Have you noticed less sensitivity in your nipples and genitals?                         [ ] Yes [ ] No

                                Personal assistance required

Minor help, relatives involved but independence is maintained                                             Y   N
Requires assistance for activities of daily living up to one hour per day from relatives or others        Y   N
Requires assistance for activities of daily living up to 3 hours a day from relatives or others           Y   N

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Requires assistance more than 3 hours but is able to live at home                                        Y       N
Institutionalization                                                                                     Y       N
      Can you do any of the following for more than 30 minutes?

Drive a car                                      Y     N   Ride in a car                                     Y       N
Ride the bus                                     Y     N   Sit in bleachers                                  Y       N
Sit in a pew                                     Y     N   Sit on a bar stool                                Y       N
Sit on a park bench                              Y     N   Sit on a sofa                                     Y       N
Sit on a soft chair                              Y     N   Sit at the dinner table                           Y       N
Sit in the commode                               Y     N   Sit on grass                                      Y       N
Sit Indian style                                 Y     N
    Explain goals you believe pain management may help you with
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

                           Please Describe Your Current Pain
Where is it?________________________________________________________________________________

Does it radiate anywhere? (arms, legs, chest, abdomen)____________________________________________

__________________________________________________________________________________________

Check the words which best describe your pain.

            Aching [ ]    Sharp [ ]     Gnawing [ ]    Throbbing [ ]     Shooting [ ]     Cramping [ ]

        Tightness [ ]    Stabbing [ ]    Tearing [ ]   Deep [ ]     Searing [ ]      Other______________

Is the pain constant?_________________________________________________________________________

What makes your pain feel better?_____________________________________________________________

What makes your pain feel worse?______________________________________________________________




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                           SKYVIEW MEDICAL CENTER
Circle the number between 0 – 10 that represents the intensity of your pain.

                                              0 = No Pain

5 = Pain interferes with your ability to function                       10 = Worst Pain imaginable

Your average pain = 0         1       2       3         4       5       6       7       8       9    10

Your worst pain = 0       1       2       3         4       5       6       7       8       9       10




                PLEASE MARK THE AREAS THAT GIVE YOU TROUBLE


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                             SKYVIEW MEDICAL CENTER




 Use above scale to rate pain while performing these activities

Doing a load of laundry
Mopping the kitchen floor, vacuuming, wiping down a counter, sweeping
Riding in a car for 30 minutes
A week’s worth of grocery shopping
Walking around the block twice
Climbing stairs
Putting on a pair of shoes
Five minutes of stretching




Patient Signature________________________________________________________________________________

Patient Name (print)____________________________________________________________________________

Today’s Date_____/_____/_______                                         Date of Birth_____/_____/_______

                  If person filling out form is different than the patient
Signature________________________________________ Today’s Date_____/_____/______

Print Name_______________________________________ Date of Birth_____/_____/______


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                                  SKYVIEW MEDICAL CENTER
                                             H.I.P.A.A. FORM
                                             NOTICE TO PATIENTS
Notice of Privacy Practice: You have provided a copy of our Notice of Privacy practices. A copy of our Notice of Privacy
Practices is also posted on our website and available at our office complies with HIPAA (Health Insurance Portability
and Accountability Act of 1996) and all federal states laws governing the privacy of your information. If you have any
questions regarding the information in the notice, please contact the representative designated in this notice.

Use of Information: By signing this form, you consent to our use and disclosure of your Protected Health Information
(PHI) to carry out Treatment, Payment activities, and Healthcare Operations (TPO). You are also acknowledging receipt,
understanding and agreement to our Notice of Privacy Practices. This duration of this consent is indefinite and continues
until revoked in writing.

You may refuse to sign this authorization.

                          I wish to be contacted in the following manner (check all that apply)



[ ] HOME TELEPHONE____/____/______                                       [ ] WRITTEN COMMUNICATION

[ ] Ok to leave a message with detailed information                      [ ] Ok to fax to this number ____/____/______

[ ] Leave a message with call back number only



[ ] WORK NUMBER____/____/______                                          [ ] OTHER______________________________

[ ] Ok to leave a message with detailed information                      ______________________________________

[ ] Leave message with call back number only                             ______________________________________



Patient Name___________________________________                                    Date of Birth_____/______/_______

Signature (Responsible Party) ____________________________________________________

Today’s Date_____/_____/_______




                                             SKYVIEW MEDICAL CENTER
                                                                                                                   18
                           SKYVIEW MEDICAL CENTER

I, _______________________________, understand that many people may contact Skyview
Medical Center with information about me. I authorize Skyview Medical Center to receive any
such material. The office of Skyview Medical Center shall follow H.I.P.A.A. guidelines about
divulging any information. I authorize the office of Skyview Medical Center to waive H.I.P.A.A.
protections and to freely discuss any aspect of my care with one or all of the following parties:



Name #1___________________________________Phone Number______________________

Address_______________________________City_______________State/Zip______________

Relationship to Patient__________________________________________________________



Name #2___________________________________Phone Number______________________

Address_______________________________City_______________State/Zip______________

Relationship to Patient__________________________________________________________



Name #3___________________________________Phone Number______________________

Address_______________________________City_______________State/Zip______________

Relationship to Patient__________________________________________________________



Patient Name (Print)_______________________________Today’s Date_____/_____/______



Patient Name (Sign)________________________________Date of Birth_____/_____/______

                                  SKYVIEW MEDICAL CENTER
                                                                                            19
                                 SKYVIEW MEDICAL CENTER
Benefits      Reduced pain, increased sleep and decreased fatigue, improved function at work and increased mood and
              enjoyment of life.

Risks         Side effects such as constipation, sedation, nausea, vomiting, and itching are the most common side effects. A
              serious and potentially fatal side effect is respiratory depression. This usually only occurs at very high doses and to
              patients who take other drugs with addictive side effects such as tranquilizers, muscle relaxers or sleeping
              medicine. You are also at increased risk for respiratory depression if you have a respiratory condition such as
              asthma. It is important to tell your doctor if you are taking any other medicines and if you have any other medical
              conditions when he takes your medical history. You must not use alcohol or any other recreational drugs if you are
              taking opiate pain medicine as this can cause potentially fatal respiratory depression. You must also inform your
              doctor if you have kidney, liver or gastrointestinal problems. Opiate medicine can be dangerous or even fatal in
              some of these conditions.

Tolerance     You may develop tolerance to Opiate medications. This means that you will need to increase the dose in order to
              continue to get pain relief. You should never do this on your own. If the medication is not working you must
              inform your doctor and he will adjust the dose. After 4 to 6 months of treatment, your doctor will attempt to
              lower the dose of the medication and wean you slowly from the medication. You should never stop medication
              suddenly as this may precipitate a syndrome known as withdrawal. This can be uncomfortable with rapid
              heartbeat, shaking, sweating, or more serious symptoms including the development of convulsions or death. If you
              experience withdrawal symptoms, call your doctor and proceed to the emergency room or call 911 immediately.

Addiction     Certain patients are psychologically prone to addiction, which is not the same as tolerance. Addiction is
              psychosocial dependence on the medication for reasons other than the pain management. If you have ever had a
              substance abuse problem or have been treated for a psychiatric condition it is important to tell your doctor this
              when he takes your history. You will be referred to the appropriate specialist in this case.

Sedation      If your work requires you to operate hazardous machinery or be in a state of optimum concentration, be aware
              that Opiate medication can cause sedation and decreased concentration. Do not participate in hazardous activities
              until you and your doctor have assessed the medication effect on you and you are familiar with them.

Alternative   Other medications such as Non- Steroidal Anti- Inflammatory, muscle relaxers, and anti- anxiety medications, form
              of physical therapy.

Treatment     Modalities (heat, ice, ultrasound, rehabilitative exercises, etc.) are all forms of treatment that can be used. Each
              carries its own risks and benefits, which have been explained by your doctor. It is generally recommended that
              your pain management program include physical therapy where possible and often other medication are used as
              an adjunct to Opiate pain medication. Opiate pain medication is indicated where these alternative forms of
              therapy alone have failed to control your pain.

              I have read the preceding two pages regarding risks, benefits of the proposed treatment and have been given an
              explanation of these as well alternative forms of treatment. I understand these and have had ample time to
              discuss these with my physician.

              The purpose of this agreement is to prevent misunderstandings about certain medications.



Patient Signature ___________________________________Today’s Date_____/_____/_____


                                            SKYVIEW MEDICAL CENTER
                                                                                                                              20
                           SKYVIEW MEDICAL CENTER

                                  REFUND POLICY
NO REFUNDS WILL BE GRANTED FOR ANY INDIVIDUAL DISCHARGED FOR ANY CAUSE
INCLUDING BUT NOT LIMITED TO THE FOLLOWING:

   A)   Failing to provide a witnessed drug screen or failing a drug screen.
   B)   Any unlawful activity or conduct.
   C)   Counterfeit or modified MRI report or any other documentation.
   D)   Providing false information or withholding information pertinent to proper treatment or
        diagnosis.

Any refund requested for any other reason other than those listed will be granted or denied
based on an individual basis.

If you have any questions you may speak with the manager.



I understand and agree that in the event of suspected illegal activity or misconduct on my
part that I may be subject to search and seizure of contraband items or substances on my
person or in my vehicle or the vehicle I arrived in while on the premises of this office, and
that by signing this agreement I hereby give my consent to the Security Department
Personnel of Skyview Medical Center to conduct search and seizure.



Patient Name (Print)_______________________________Today’s Date____/_____/_____



Patient Name (Sign) _______________________________Date of Birth____/_____/_____




                                  SKYVIEW MEDICAL CENTER
                                                                                              21
                               SKYVIEW MEDICAL CENTER
                    AGREEMENT FOR THE MANAGEMENT OF CONTROLLED SUBSTANCES

This agreement is made voluntary between _________________________ and Skyview Medical Center to
insure the safe, ethical and legal usage of controlled substances. Controlled substances are medications that
have a high abuse, addiction and diversion potential. Complete and absolute truthfulness is essential for the
safe use of these drugs.

Failure to honestly communicate to the staff and to carefully follow this agreement can lead to addiction,
incarceration or your death. YOU ARE RESPONSIBLE FOR YOUR OWN ACTIONS AND FOR YOUR
MEDICATIONS.

You will be expected to agree to comply with the treatment plan established for you. Your treatment plan may
include: MRIs, CT Scans, X-Rays, Laboratory Tests, Steroid Injections and possibly, a Nerve Stimulator Trial
and/or a Narcotic Pain Pump Trial. Your treatment plan will be established based on your individual diagnosis
and situation.

The purpose of Skyview Medical Center is to treat chronic pain problems in an ethical and medically
responsible manner and to improve the quality of your life. If your life is not improved by taking controlled
medications, you must tell the Skyview Medical Center staff so that we may assist you to get off these
dangerous medications.

   1. Controlled substances are potentially dangerous and can lead to your death. By signing this
      Agreement, you agree to be completely responsible for all medications you are given by Skyview
      Medical Center.
   2. You must immediately report lost, stolen or misplaced medications. Failure to do this may lead to
      your discharge from the clinic. No replacements will be given for lost, stolen or misplaced
      medications. More than one report of lost, stolen or misplaced medications may lead to your
      discharge. DO NOT ASK FOR REPLACEMENT MEDICATIONS! You must report lost or stolen
      medications within 24 (twenty-four) hours and you will be required to report to the office with all
      remaining medications for a urinary drug screen. There will be no exceptions made.
   3. Controlled substances can lead to alterations in your ability to operate any automobile or any
      machinery. Skyview Medical Center does not recommend driving or operating machinery while on
      narcotics, sedatives or controlled substances. If you choose to drive or operate machinery and have an
      accident or suffer injury while on controlled substances, this is completely your responsibility. You
      must follow state law and work regulations.
   4. Controlled substances, especially narcotics such as morphine, oxycodone, methadone, dilaudid,
      fentanyl, opana and other narcotics, can lead to over sedation, sleepiness, fatigue, constipation and
      other side effects. If these or other problems occur, it is your responsibility to tell the Skyview Medical
      Center staff. Other potentially lethal complications include respiratory depression, which can lead to
      your not breathing will resulting in your death.

       a. Breathing disorders such as Asthma, Bronchitis, COPD, Emphysema, Sleep Apnea, Pneumonia and
                                        SKYVIEW MEDICAL CENTER
                                                                                                           22
                           SKYVIEW MEDICAL CENTER
        other disorders can be fatal in combination with narcotics or sedatives because of respiratory
        depression. Narcotics can worsen existing breathing problems.
    b. Alcohol in combination with narcotics or sedatives can lead to over dosage and can be fatal.
        Especially dangerous in combination with alcohol are long-acting medications such as Avinza,
        MSContin, Kadian, long-acting Morphine, Methadone, Opana, Oxycontin or any other narcotics.
    c. If you become acutely ill while on narcotics, sedatives or controlled substances, this can lead to
        over dosage and death, even if you take the medications as prescribed. IF YOU BECOME ACUTELY
        ILL, YOU MUST TELL ALL MEDICAL PERSONNEL THAT TREAT YOU THAT YOU ARE ON CONTROLLED
        SUBSTANCES. An increase in your narcotic dose can lead to respiratory depression and death.
        You must report any side effect immediately!
5. You may not have narcotics filled from another physician, dentist, or ER physician. You may be
    discharged from the clinic if you have narcotic medications filled by another provider. If you do this,
    you may be discharged and we will contact the other medical providers, pharmacies, and your
    insurance carrier. This is a serious breach of trust!
6. You are allowed to use only one pharmacy for controlled substances. Your pharmacy will require that
    you present them with a copy of this agreement. Your pharmacy will contact Skyview Medical Center if
    you receive any controlled substances from another source. If you need to change pharmacies for any
    reason, you must contact Skyview Medical Center and documentation must be included in your chart.
7. You must provide this office with a working phone number. We must be able to contact you within 24
    (twenty-four) hours. If you are going out of town you must notify the office in advance. If we are
    unable to get in contact with you within 24 (twenty-four) hours, you may be discharged from the clinic.
8. It is your responsibility to keep the clinic updated with your current phone number, address and any
    contact phone numbers so that we can contact you, if needed. There will be no exceptions made.
9. If we get a call regarding your misuse or selling of your narcotic medication, we will call you
    immediately to come in for a medication count and a urine drug screen. There will be no exceptions
    made. In some instances, law enforcement may be notified.
10. You cannot smoke marijuana, use cocaine or other illegal substances. If you test positive for illegal
    substances, you will be discharged IMMEDIATELY.
11. You must not take more medication than you are prescribed! Taking more medication than you are
    prescribed can lead to addiction, over dosage or death. You must have approval to take more
    medication than prescribed and this must be documented in your chart. If you take more medication
    than prescribed without prior approval, you may be discharged. YOU ARE RESPONSIBLE FOR THE
    MEDICATION THAT YOU TAKE!
12. You must bring all controlled substances and any other medications Skyview Medical Center may
    prescribe for you in their original bottles each and every time you visit Skyview Medical Center.
    THERE WILL NOT BE EXCEPTIONS! If you go to the Emergency Room for any reason, you must take all
    your controlled substances with you and must tell them you have a contract with Skyview Medical
    Center for controlled substances. Failure to do this may lead to discharge. Never attempt to obtain or
    take controlled substances from friends, family members or any medical practitioner while under the
    care of Skyview Medical Center. This includes controlled substances from the Emergency Room or a
    dentist.
13. If we have any concerns over your usage of controlled substances, you will be required to undergo
                                   SKYVIEW MEDICAL CENTER
                                                                                                     23
                              SKYVIEW MEDICAL CENTER
       appropriate urine testing to verify that you are taking the medications prescribed for you. Failure to
       comply with mandatory urine screening may result in discharge from this clinic. You must agree to
       random urine drug screens. The number of urine drug screens per year may vary.

If you have any side effects or feel that the controlled substances are causing any problems or impairment,
you must stop taking them and immediately and report this to Skyview Medical Center. Lack of good
communication can lead to your death! Selling or illegally buying controlled substances is a serious is a
serious crime and could lead to your death. If you are arrested on any drug or alcohol related charges, you
may be discharged from the clinic.

Never leave your controlled substances unguarded as they may be stolen or misused. It is your
responsibility to safeguard all your medications at all times. Never, under any circumstances, leave
controlled substances unattended in an automobile, as this is reckless and inappropriate behavior. If you
must carry your narcotic medications with you while traveling, keep them in the prescription bottle in which
they were filled at the pharmacy. It is illegal to travel with unidentified medications.

KEEP ALL MEDICATIONS OUT OF THE REACH OF CHILDREN

By signing this contract, you are agreeing to hold harmless the physician and/or staff at Skyview Medical
Center for any harmful act(s) that you may commit, for any error of judgment or faulty legal decision that you
may make while taking any controlled substances from Skyview Medical Center. Controlled substances can
affect judgment.

By signing this contract, you are agreeing that you have read, or have had this document read to you and
that you understand this content. You are acknowledging that you had a chance to ask questions and to
have all you questions answered.

You will be asked to renew this contract every six (6) months or more often if revisions are made to the
document.


 Please sign this contract only in the presence of a staff member of Skyview Medical Center.




Patient Signature _________________________________ Date ____/____/______              Time ____:____am/pm



Witness ________________________________________ Date ____/____/______

                                       SKYVIEW MEDICAL CENTER
                                                                                                         24
                          SKYVIEW MEDICAL CENTER


(Females Only):

Narcotics can have risk for development of birth defects. However,
if I continue to take these medications throughout pregnancy, my
child may be born drug-dependent and need specialized care. I
therefore agree that if I plan to become pregnant, or believe I have
become pregnant while on these medications, I will immediately
notify my doctor.




Pharmacy Information
I agree to use_________________________________________________________Pharmacy.



Located at (address)____________________________________________________________

Telephone Number_____________________for filling prescriptions for all pain medicine.

I agree to follow these guidelines that have been fully explained to me. All of my questions and
   concerns regarding treatment have been adequately answered. A copy of this agreement is
                   entered into on the ______ day of _____________, _____.
                                 SKYVIEW MEDICAL CENTER
                                                                                           25
                               SKYVIEW MEDICAL CENTER
                    AGREEMENT FOR THE MANAGEMENT OF CONTROLLED SUBSTANCES
                                               PATIENT COPY
This agreement is made voluntary between _________________________ and Skyview Medical Center to
insure the safe, ethical and legal usage of controlled substances. Controlled substances are medications that
have a high abuse, addiction and diversion potential. Complete and absolute truthfulness is essential for the
safe use of these drugs.

Failure to honestly communicate to the staff and to carefully follow this agreement can lead to addiction,
incarceration or your death. YOU ARE RESPONSIBLE FOR YOUR OWN ACTIONS AND FOR YOUR
MEDICATIONS.

You will be expected to agree to comply with the treatment plan established for you. Your treatment plan may
include: MRIs, CT Scans, X-Rays, Laboratory Tests, Steroid Injections and possibly, a Nerve Stimulator Trial
and/or a Narcotic Pain Pump Trial. Your treatment plan will be established based on your individual diagnosis
and situation.

The purpose of Skyview Medical Center is to treat chronic pain problems in an ethical and medically
responsible manner and to improve the quality of your life. If your life is not improved by taking controlled
medications, you must tell the Skyview Medical Center staff so that we may assist you to get off these
dangerous medications.

   1. Controlled substances are potentially dangerous and can lead to your death. By signing this
      Agreement, you agree to be completely responsible for all medications you are given by Skyview
      Medical Center.
   2. You must immediately report lost, stolen or misplaced medications. Failure to do this may lead to
      your discharge from the clinic. No replacements will be given for lost, stolen or misplaced
      medications. More than one report of lost, stolen or misplaced medications may lead to your
      discharge. DO NOT ASK FOR REPLACEMENT MEDICATIONS! You must report lost or stolen
      medications within 24 (twenty-four) hours and you will be required to report to the office with all
      remaining medications for a urinary drug screen. There will be no exceptions made.
   3. Controlled substances can lead to alterations in your ability to operate any automobile or any
      machinery. Skyview Medical Center does not recommend driving or operating machinery while on
      narcotics, sedatives or controlled substances. If you choose to drive or operate machinery and have an
      accident or suffer injury while on controlled substances, this is completely your responsibility. You
      must follow state law and work regulations.
   4. Controlled substances, especially narcotics such as morphine, oxycodone, methadone, dilaudid,
      fentanyl, opana and other narcotics, can lead to over sedation, sleepiness, fatigue, constipation and
      other side effects. If these or other problems occur, it is your responsibility to tell the Skyview Medical
      Center staff. Other potentially lethal complications include respiratory depression, which can lead to
      your not breathing will resulting in your death.



                                        SKYVIEW MEDICAL CENTER
                                                                                                           26
                           SKYVIEW MEDICAL CENTER
    d. Breathing disorders such as Asthma, Bronchitis, COPD, Emphysema, Sleep Apnea, Pneumonia and
        other disorders can be fatal in combination with narcotics or sedatives because of respiratory
        depression. Narcotics can worsen existing breathing problems.
    e. Alcohol in combination with narcotics or sedatives can lead to over dosage and can be fatal.
        Especially dangerous in combination with alcohol are long-acting medications such as Avinza,
        MSContin, Kadian, long-acting Morphine, Methadone, Opana, Oxycontin or any other narcotics.
    f. If you become acutely ill while on narcotics, sedatives or controlled substances, this can lead to
        over dosage and death, even if you take the medications as prescribed. IF YOU BECOME ACUTELY
        ILL, YOU MUST TELL ALL MEDICAL PERSONNEL THAT TREAT YOU THAT YOU ARE ON CONTROLLED
        SUBSTANCES. An increase in your narcotic dose can lead to respiratory depression and death.
        You must report any side effect immediately!
5. You may not have narcotics filled from another physician, dentist, or ER physician. You may be
    discharged from the clinic if you have narcotic medications filled by another provider. If you do this,
    you may be discharged and we will contact the other medical providers, pharmacies, and your
    insurance carrier. This is a serious breach of trust!
6. You are allowed to use only one pharmacy for controlled substances. Your pharmacy will require that
    you present them with a copy of this agreement. Your pharmacy will contact Skyview Medical Center if
    you receive any controlled substances from another source. If you need to change pharmacies for any
    reason, you must contact Skyview Medical Center and documentation must be included in your chart.
7. You must provide this office with a working phone number. We must be able to contact you within 24
    (twenty-four) hours. If you are going out of town you must notify the office in advance. If we are
    unable to get in contact with you within 24 (twenty-four) hours, you may be discharged from the clinic.
8. It is your responsibility to keep the clinic updated with your current phone number, address and any
    contact phone numbers so that we can contact you, if needed. There will be no exceptions made.
9. If we get a call regarding your misuse or selling of your narcotic medication, we will call you
    immediately to come in for a medication count and a urine drug screen. There will be no exceptions
    made. In some instances, law enforcement may be notified.
10. You cannot smoke marijuana, use cocaine or other illegal substances. If you test positive for illegal
    substances, you will be discharged IMMEDIATELY.
11. You must not take more medication than you are prescribed! Taking more medication than you are
    prescribed can lead to addiction, over dosage or death. You must have approval to take more
    medication than prescribed and this must be documented in your chart. If you take more medication
    than prescribed without prior approval, you may be discharged. YOU ARE RESPONSIBLE FOR THE
    MEDICATION THAT YOU TAKE!
12. You must bring all controlled substances and any other medications Skyview Medical Center may
    prescribe for you in their original bottles each and every time you visit Skyview Medical Center.
    THERE WILL NOT BE EXCEPTIONS! If you go to the Emergency Room for any reason, you must take all
    your controlled substances with you and must tell them you have a contract with Skyview Medical
    Center for controlled substances. Failure to do this may lead to discharge. Never attempt to obtain or
    take controlled substances from friends, family members or any medical practitioner while under the
    care of Skyview Medical Center. This includes controlled substances from the Emergency Room or a
    dentist.
                                   SKYVIEW MEDICAL CENTER
                                                                                                     27
                              SKYVIEW MEDICAL CENTER
   13. If we have any concerns over your usage of controlled substances, you will be required to undergo
       appropriate urine testing to verify that you are taking the medications prescribed for you. Failure to
       comply with mandatory urine screening may result in discharge from this clinic. You must agree to
       random urine drug screens. The number of urine drug screens per year may vary.

If you have any side effects or feel that the controlled substances are causing any problems or impairment,
you must stop taking them and immediately and report this to Skyview Medical Center. Lack of good
communication can lead to your death! Selling or illegally buying controlled substances is a serious is a
serious crime and could lead to your death. If you are arrested on any drug or alcohol related charges, you
may be discharged from the clinic.

Never leave your controlled substances unguarded as they may be stolen or misused. It is your
responsibility to safeguard all your medications at all times. Never, under any circumstances, leave
controlled substances unattended in an automobile, as this is reckless and inappropriate behavior. If you
must carry your narcotic medications with you while traveling, keep them in the prescription bottle in which
they were filled at the pharmacy. It is illegal to travel with unidentified medications.

KEEP ALL MEDICATIONS OUT OF THE REACH OF CHILDREN

By signing this contract, you are agreeing to hold harmless the physician and/or staff at Skyview Medical
Center for any harmful act(s) that you may commit, for any error of judgment or faulty legal decision that you
may make while taking any controlled substances from Skyview Medical Center. Controlled substances can
affect judgment.

By signing this contract, you are agreeing that you have read, or have had this document read to you and
that you understand this content. You are acknowledging that you had a chance to ask questions and to
have all you questions answered.

You will be asked to renew this contract every six (6) months or more often if revisions are made to the
document.

 Please sign this contract only in the presence of a staff member of Skyview Medical Center.




Patient Signature _________________________________ Date ____/____/______              Time ____:____am/pm



Witness ________________________________________ Date ____/____/______

                                       SKYVIEW MEDICAL CENTER
                                                                                                         28
                          SKYVIEW MEDICAL CENTER
(Females Only):

Narcotics can have risk for development of birth defects. However,
if I continue to take these medications throughout pregnancy, my
child may be born drug-dependent and need specialized care. I
therefore agree that if I plan to become pregnant, or believe I have
become pregnant while on these medications, I will immediately
notify my doctor.




Pharmacy Information
I agree to use_________________________________________________________Pharmacy.



Located at (address)____________________________________________________________

Telephone Number_____________________for filling prescriptions for all pain medicine.

I agree to follow these guidelines that have been fully explained to me. All of my questions and
concerns regarding treatment have been adequately answered. A copy of this agreement is
entered into on the ______ day of _____________, _____.


                                  SKYVIEW MEDICAL CENTER
                                                                                           29
                          SKYVIEW MEDICAL CENTER

                            DISCHARGE OF PATIENT CARE

Regrettably, some patients will be discharged from our practice. There are many reasons why
this can happen. Skyview Medical Center will tell the individual involved what the specific
difficulty may be.

Skyview Medical Center may be available for emergency coverage only for 30 days from the
date of discharge.

Skyview Medical Center will not prescribe any narcotic pain medication during this transaction
period.

Skyview Medical Center may or may not choose to offer medications for the symptoms of
withdrawal.

Skyview Medical Center will not assist in finding a new pain management practice to handle
your future pain needs.

If Skyview Medical Center is contacted by another pain management service, we will tell the
truth as to what transpired in this office.

If you have been discharged, we will not accept any telephone, fax or email contact. The only
way to communicate will be by US Postal Service certified mail.




Patient Signature: _______________________________                   Date: ____/____/______




                                 SKYVIEW MEDICAL CENTER
                                                                                          30
                      SKYVIEW MEDICAL CENTER

I, _______________________________________________________,
understand that I must bring all of my medications to my first
appointment. This includes everything that I take in their bottles. If I do
not bring my medications, I will not be seen and will not be rescheduled.


Patient Signature: _____________________________________________


Date: ____/____/______




I realize and understand that for the first “4” (four) visits I will be at the
office for at least 3-5 hours.


Patient
Signature:______________________________________________


Date: ____/____/______

                            SKYVIEW MEDICAL CENTER
                                                                             31
                     SKYVIEW MEDICAL CENTER

Effective immediately, Skyview Medical Center will be implementing a NO SHOW
and NO CANCELLATION of appointments policy. There must be 24 hour notice
of any appointment change or cancellation.


                 NO SHOW & NO CANCELLATION FEES


   New patient NO SHOW and NO CANCELLATION will not be rescheduled.
   Follow-up and/or office visit NO SHOW and NO CANCELLATION will not
    be worked in, and medications will not be written until an appointment is
    available.
   Anyone who is 15 minutes late or more will be rescheduled, and medications
    will not be written until an appointment is available.
Three (3) NO SHOWS with Skyview Medical Center will result in a discharge from
this practice.


I, _____________________________________, understand and have read
Skyview Medical Center’s new policy on NO SHOW and NO CANCELLATION
POLICY.


Patient Signature: ___________________________________________


Date: ____/____/______

                           SKYVIEW MEDICAL CENTER
                                                                          32
                            SKYVIEW MEDICAL CENTER



                     H.I.P.P.A. WAIVER AND CONSENT FORM




For the purpose of quality assurance, performance evaluation and
security, the undersigned hereby understands and agrees that
members of the clinical staff and/or security department of Skyview
Medical Center, its agents, servants or employees, may be present at
any and all times during specimen donation/collections, triage and
medical interview, examination and or procedure by medical
physicians/practitioners.




____________________________________________                 _____/_____/________
Signature                                                    Date



________________________________________________________     _______/_______/_________

Witness                                                      Date




                                    SKYVIEW MEDICAL CENTER
                                                                                         33
                                    SKYVIEW MEDICAL CENTER

Name: __________________________________                     D.O.B.: _____/_____/______            Date: _____/_____/______

                                                              COMM

  Please answer each question as honestly as possible. Keep in mind that we are only asking about the past 30
  days. There is no right or wrong answer. If you are unsure about how to answer the question, please give the
                                              best answer you can.

Please answer the questions using the following




                                                                                           Never

                                                                                                   Seldom

                                                                                                            Sometimes




                                                                                                                        Often


                                                                                                                                Often
                                                                                                                                Very
scale:

                                                                                            0        1            2      3       4
In the past 30 days, how often have you had trouble with thinking clearly or had memory     []       []           []     []      []
problems?
In the past 30 days, how often do people complain that you are not completing necessary     []       []           []     []      []
tasks? (i.e., doing things that need to be done, such as going to class, work or
appointments. )
In the past 30 days, how often have you had to go to someone other than your prescribing    []       []           []     []      []
physician to get sufficient pain relief from medications? (i.e., another doctor, the
Emergency Room, friends, street sources)
In the past 30 days, how often have you taken your medications differently from how         []       []           []     []      []
they are prescribed?
In the past 30 days, how often have you seriously thought about hurting yourself?           []       []           []     []      []
In the past 30 days, how much of your time was spent thinking about opioid medications      []       []           []     []      []
(having enough, taking them, dosing schedule, etc.)?
In the past 30 days, how often have you been in an argument?                                []       []           []     []      []
In the past 30 days, how often have you had trouble controlling your anger (e.g., road      []       []           []     []      []
rage, screaming, etc.)?
In the past 30 days, how often have you needed to take pain medications belonging to        []       []           []     []      []
someone else?
In the past 30 days, how often have you been worried about how you’re handling your         []       []           []     []      []
medications?
In the past 30 days, how often have others been worried about how you’re handling your      []       []           []     []      []
medications?
In the past 30 days, how often have you had to make an emergency phone call or show         []       []           []     []      []
up at the clinic without an appointment?
In the past 30 days, how often have you gotten angry with people?                           []       []           []     []      []
In the past 30 days, how often have you had to take more of your medication than            []       []           []     []      []
prescribed?
In the past 30 days, how often have you borrowed pain medication from someone else?         []       []           []     []      []
In the past 30 days, how often have you used your pain medication for symptoms other        []       []           []     []      []
than for pain (e.g., to help you sleep, improve your mood, or relieve stress)?
In the past 30 days, how often have you had to visit the Emergency Room?        []      []      []                       []      []
                       A score of two (2) or above must be addressed by the other practitioner.


                                              SKYVIEW MEDICAL CENTER
                                                                                                                                34
                                    SKYVIEW MEDICAL CENTER
   Total Score: ______         Signed: ____________________________________ Date: _____/_____/_______

                                                           SOAPP-R

Please answer the questions using the following scale:




                                                                                                             Sometimes



                                                                                                                                 Very Often
                                                                                                    Seldom
                                                                                            Never




                                                                                                                         Often
                                                                                             0       1         2          3         4
How often do you have mood swings?                                                           []      []        []         []        []
How often have you felt a need for higher doses of medication to treat your pain?            []      []        []         []        []
How often have you felt impatient with your doctors?                                         []      []        []         []        []
How often have you felt that things are just too overwhelming that you can’t handle them?    []      []        []         []        []
How often is there tension in the home?                                                      []      []        []         []        []
How often have you counted pain pills to see how many are remaining?                         []      []        []         []        []
How often have you been concerned that people will judge you for taking pain medication?     []      []        []         []        []
How often do you feel bored?                                                                 []      []        []         []        []
How often have you taken more pain medication than you were supposed to?                     []      []        []         []        []
How often have you worried about being left alone?                                           []      []        []         []        []
How often have you felt a craving for medication?                                            []      []        []         []        []
How often have others expressed concern over your use of medication?                         []      []        []         []        []
How often have any of your close friends had a problem with alcohol or drugs?                []      []        []         []        []
How often have others told you that you had a bad temper?                                    []      []        []         []        []
How often have you felt consumed by the need to get pain medication?                         []      []        []         []        []
How often have you run out of pain medication early?                                         []      []        []         []        []
How often have others kept you from getting what you deserve?                                []      []        []         []        []
How often, in your lifetime, have you had legal problems or been arrested?                   []      []        []         []        []
How often have you attended an AA or NA meeting?                                             []      []        []         []        []
How often have you been in an argument that was so out of control that someone got hurt?     []      []        []         []        []
How often have you been sexually abused?                                                     []      []        []         []        []
How often have others suggested that you have a drug or alcohol problem?                     []      []        []         []        []
How often have you had to borrow pain medications from your family or friends?               []      []        []         []        []
How often have you been treated for an alcohol or drug problem?                              []      []        []         []        []




    Total Score: _________ Signed: __________________________________ Date: _____/_____/_______




                                              SKYVIEW MEDICAL CENTER
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SKYVIEW MEDICAL CENTER




   SKYVIEW MEDICAL CENTER
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posted:10/31/2011
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