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Patient Questionaire

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APPOINTMENT

innova Pain Center accepts new and existing patient appointments Monday through Friday.

Monday 8:15am – 11:45am 1:00pm – 3:45pm
Tuesday 8:15am – 11:45am 1:00pm – 3:45pm
Wednesday 8:15am – 11:45am 1:00pm – 3:45pm
Thursday 8:15am – 11:45am 1:00pm – 3:45pm
Friday 8:15am – 11:45am 1:00pm – 3:45pm

Appointment

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INSURANCE AFFILIATIONS

innova is dedicated to providing you with the highest quality, cost effective medical care. We accept all major insurance policies and credit cards.

AARP

Aetna

Assurant

Health

BCBS Texas

Champva

Cigna

CORBA

Evercare

Golden Rule

Health Spring

Humana

KNOW MORE

Welcome to innova Pain Center.

For your convenience and to save time, we have provided the opportunity to fill out your new patient forms online. PLEASE FOLLOW THE EASY 3 STEP PROCESS IN COMPLETING YOUR NEW PATIENT FORMS. Upon completion your forms will be automatically submitted on your behalf.

    Name: Email: Date:
    DOB: Height:Weight:
    Referring Physician Name and Number:PCP Name and Number:
    Where is your pain?How long have you had this pain?
    Did any particular event cause the pain to start?.  If yes, what:
    Please place an “X” where you are experiencing pain.

    Please Place experiencing pain
    Front:1234567  Back:1234567
    Does your pain travel?.  If yes, where?

    Rate your pain over the last week, with 0 as no pain and 10 as the worst pain.

    Worst Pain:
    Least Pain:
    Usually:
    Right Now:
    Acceptable Level:

    Please mark the following items that best describe your pain.
    DullSharpNumbStabbingBurningAching
    ThrobbingTenderCrampingPressureShootingStinging
    With associated:
    WeaknessNumbnessTinglingBowel/Bladder DysfunctionNo Associated Symptoms
    How would you describe your pain?
    ConstantIntermittent
    When is your pain typically worse?
    MorningAfternoonNightDoesn’t Matter
    What makes your pain worse?
    StandingWalkingSittingBendingPhysical ActivityCoughingColdHeatOther
    If other Then please Describe
    What makes your pain better?
    Being StillStandingWalkingSittingLying downBendingColdHeatMassagePain medicationsOther
    Please Descirbe
    How much does the pain interfere with your life (circle one)?
    012345678910
    What types of treatment have you tried? Example: Physical Therapy, Injections, MassagePlease Specify:
    What type of relief did you receive? ExcellentGoodFairPoor
    Please list ALL pain medications that you are currently on or that you have ever used. (use the back of the paper if you need more space):

    Name Dose Frequency Taking
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    Are you allergic to anything?:
    Reaction to allergies?:
    Are you taking blood thinners (Aspirin, Coumadin, Plavix)?:
    Have you been diagnosed with diabetes?:
    Please check any of the following tests that you have had to diagnose your current problem.CT ScanMRI ScanEMG
    Do you have any medical problems? If so, please check:
    DiabetesHypertensionHeart DiseaseCOPDHigh CholesterolOther
    Other
    Have you had any surgeries? If so, please check:
    Neck SurgeryBack SurgeryAppendectomyGallbladderHysterectomyC-SectionOther
    Other
    Do you have any of the following symptoms?
    FeverDecreased VisionDecreased HearingChest PainShortness of BreathConstipationIncontinenceTinglingNumbnessWeaknessSleep DifficultyDepressionAnxietyOther
    Other
    Do you smoke?: NoYesQuit

    When Quit?:

    If yes, how many packs a day?:
    How many years?:

    Do you drink alcohol? :NoYes
    If yes, how often? :
    Do you use any illegal drugs, such as marijuana, cocaine, etc.? :NoYes
    If yes, please specify :
    What is your occupation?
    Check Work status: WorkingUnemployedOff Work Due To PainRetiredDisabled