Baylor Center for Pain Management
Dear ______________________________,
We want to confirm your initial appointment with:
Benjamin Wiseman, M.D.
on _________________________ at ____________
Enclosed is a packet of information that you need to COMPLETE AND SIGN prior to your visit.
Please arrive 30 minutes prior to your scheduled appointment time with these forms completed.
This will allow us ample time to pre-register you for your appointment.
If you are late, you may need to be rescheduled to another day. Thank you.
Please bring the following with you:
 Picture I.D. and Insurance Card(s)
 If applicable, Workers’ Compensation information
 Personal check, Cashier’s check or Money order for your co-payment/outpatient deductible.
If you are uninsured, please bring the total amount for the office visit and possible injection.
 Insurance referral number for your visit (contact your primary care physician or insurance company
if you have any questions).
Your appointment will take place at the:
BAYLOR CENTER FOR PAIN MANAGEMENT
600 Cooper, Suite 110
Wylie, Texas 75098
This is a consultation and/or possible procedure ONLY. All procedures must be pre-approved by your
insurance company. If you have any questions, please call us at 972.442.7500.
We look forward to seeing you.
a:\new pt pkt.doc
Patient Name _______________________ Date of Birth: _____________ Date: ______________
Current Medications
Medication
Dose
Frequency
Start Date
Reason for Taking
Prescribing
Doctor
Medication Allergies
Medicine
Allergy Symptoms – Describe Reaction
Signatures
Patient/Patient Informant Signature
Clinician Signature
Date / Time
Patient Name: ____________________________ Date of Birth: ____________ Date:____________
Medical Problems ( i.e. diabetes, hypertension, etc.)
Active Problems
Date of onset
Date Resolved
(to be updated by the physician
when the problem is resolved)
Previous Problems:
Surgical Procedures
Type of Surgery
Date of Surgery
New Patient Information Record
FULL LEGAL NAME:
Last Name: ___________________________ First: ___________________________ Middle: ___________________
Address ___________________________________ City __________________ State _____ _______ Zip _________
Home Phone: (
) ___________________________ Cell Phone: (
)_________________________________
Date of Birth: ________________ Sex: ______ SSN:
Email Address:
Ethnicity: _______________
Marital Status:
S
M
D
W
O
PATIENT EMPLOYER’S INFORMATION:
[ ] Currently employed
[ ] Unemployed
[ ] Legally Disabled
Company Name: ___________________________________Work phone: (
[ ] Retired - Retirement date:
) _____________________________
IF MARRIED, PLEASE LIST SPOUSE’S EMPLOYMENT INFORMATION:
Spouse’s Name:
Employer: _____________________ or Retirement Date :
Work phone:
Address:
City:
State:
Zip: _________
EMERGENCY CONTACTS:
1. Name:
Relationship:
Phone #: (
)
2. Name:
Relationship:
Phone #: (
)
PRIMARY CARDHOLDER INFORMATION
(IF DIFFERENT FROM PATIENT):
- Check if same as above
Name: ___________________________ D.O.B.___________
SS#:_____________________ Relationship: ____________
Home Address: _____________________________________ City: ____________ State: ________ Zip: __________
Home Phone: __________________ Cardholder’s employer: _________________________ Work #: ______________
Primary Insurance Company: ___________________________ __________________________________________
Secondary Insurance Company: __________________________ __________________________________________
PHYSICIAN INFORMATION:
Referring Physician: ____________________________________ Phone: ___________________________________
Primary Care Physician (PCP): ___________________________________ Phone: ____________________________
Address: _______________________________________ City: ____________ State: _________ Zip Code: ________
***************************************************************************
If your pain is a result of an injury at work, please fill out the following section:
WORKERS’ COMPENSATION INFORMATION:
Date of Injury: _____________ Claim #: __________________________ Insurance Carrier: _____________________
Street Address: __________________________________ City: __________________ State: ______ Zip: _________
Phone #: (
) ___________________________
Adjuster: ___________________________________________
Employer at time of injury: ___________________ Brief description of accident: _______________________________
Employer’s address at time of injury: ___________________________________________________________________
Treating MD: _________________ Street Address: ______________________________________________________
City: _________________________
State: ____________ Zip: ____________ Phone: __________________
***************************************************************************
For all patients:
Circle one
(Y)
(N)
INSURANCE AUTHORIZATION
I hereby authorize physician: Haynsworth / Ravula / Clark, to furnish information to my insurance carriers
concerning my illness and treatment.
(Y)
(N)
ASSIGNMENT OF BENEFITS
I hereby assign to physician: Haynsworth / Ravula all payments for medical services rendered to my
dependents or myself. I understand that I am responsible for any amount not covered by insurance.
(Y)
(N)
TREATMENT AUTHORIZATION
I hereby authorize physician: Haynsworth / Ravula, to render health care to me during this visit.
SIGNATURE:
DATE: _______________________
New patient questionnaire
Patient Name: _________________________________DOB ________________Date: __________________
1. Where is your pain located? ________________________________________________________________________________
2. How long have you had pain?
-12 months
3. How did your pain start?
_________
4. Check the one(s) that describe your pain:
present all the time
5. Please check the kinds of doctors or specialists you have seen about this pain:
logist
urologist
6. Please rate your pain according to the following::
Mild------------------Moderate ---------------Severe
1 2
3
4 5
6
7 8
9 10
This is how my pain felt during the past week:
7. What tests have been done to try to diagnose your pain?
-rays
Findings: (if known): ________________________________________________________________
8. What other treatments have you tried to help this pain?
programs
________________________________
________________________________
______________________________
______________________________
Did any of these treatments or medications seem to help your pain?
__________________________________________
9. Please circle any family medical problems:
rostate problems
10. Please check either Yes or No to any of these which apply to you:
Yes
Married?
Do you smoke?
Do you drink daily?
History of alcohol or drug abuse?
Have you seen a psychologist or psychiatrist?
Currently under high stress?
Currently employed ?
Disabled?
Law suit pending?
Family problems?
Recent Crisis?
Current depression?
No
11. Please check any of these which apply to you:
ems
Decreased sexual interest
Abdominal Pain
Baylor Center for Pain Management
Patient’s Name:_____________________Date of Birth _____________ Date:___________
Using the symbols given below, mark the areas on your body where you feel the described
sensations. Include all affected areas.
Ache
^^^^
^^^^
^^^^
Numbness
OOOO
OOOO
OOOO
Pins & Needles
====
====
====
Burning
XXXX
XXXX
XXXX
Stabbing
////
////
////
On a scale of 0 to 10, how is your pain now?
Medication Agreement
This agreement was developed to try to decrease the risk of problems or side effects occurring
with medication prescribed through this office. Please read through each statement and initial
where requested. If there are any questions, please do not hesitate to ask.
I understand that all medications have potential risks. Although any major risks will be
discussed with you, it is impossible to talk about each potential side effect or risk of each
medication. If you want detailed information, ask us and we will give you a copy of the
PHYSICIAN’S DESK REFERENCE information on each medication. Your pharmacist can
also give you detailed information if you ask.
Initials: _________________
I will not exceed the prescribed medication amount or receive similar medication from other
sources.
Initials: _________________
If I begin to have a side effect that concerns me, I will stop the medication and notify my
physician.
Initials: __________________
Our policy is to prescribe medication during office visits and not over the telephone. Your
medication should last until your next scheduled appointment.
Initials: ___________________
MEDICATION TO STOP PRIOR TO INJECTIONS
AT THE PAIN CENTER
ASPIRIN PRODUCTS – STOP TAKING 7 DAYS BEFORE SURGERY
These include the following:
ACETYLSALICYLIC ACID PRODUCTS –
Alka-Seltzer®, Anacin®, Arthritis Pain Formula®, Ascriptin®, Aspergum®, Pepto Bismol®
ASPIRIN PRODUCTS –
Baby Aspirin, Bufferin®, Darvon Compound®, Ecotrin®, Empirin®, Equagesic®, Fiorinal®, 4Way Cold®, Genprin®, BC Powder®
Halfprin, Midol Max Stregth®, Norgesic®, Percodan®, Sine-Off®, Triaminicin Cold®,
Vanquish®, Zorprin®
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)
STOP TAKING 3 DAYS BEFOR SURGERY
These include the following:
Advil®, Bayer Select®, Excedrin IB®, Haltran®, Medipren®, Midol Cramp Formula®, Midol
IB®, Motrin®, Nuprin®, ibuprofen
Pamprin IB®, Rufen®
Arthrotec®, Cataflam®, Voltaren®, Lodine®, Ansaid®, Orudis®, Toradol®, Ponstel®,
Tolectin®, Tolectin DS®
Dolobid®, Nalfon®, Indocin®, Clinoril®
Mobic®, Relafen®, Aleve®, Anaprox®, Naprosyn®, Naproxen
ANTICOAGULANT THERAPY (BLOOD THINNERS)
STOP TAKING 7 DAYS BEFOR SURGERY
These include the following:
Warfarin (Coumadin®) 5-7 days,
Dipyridamole (Persantine®) 2 days,
Clopidrogel (Plavix®) 7-10 days,
Ticlopidine (Ticlid®) 7-10 days,
Cilostazol (Pletal®) 2 days,
Aggrenox® 14 days
Daypro, Feldene 7 days
If you have any doubt whether to continue or stop a medication prior to your
procedure, please call us at 972 231-1591.
INSTRUCTIONS for PROCEDURE PATIENTS
1. You may have a light meal such as toast 6 hours before the procedure, no fried fatty foods
or meat. You may have clear liquids 2 hours before the procedure such as water, fruit
juice without pulp, carbonated beverages, clear tea or black coffee. NO DAIRY
PRODUCTS
2. If you are a diabetic, check with your diabetes physician concerning diabetic medication
during this time of limited food. Please bring diabetic medications with you. (oral and
insulin)
3. If you are on blood thinners, your primary physician can give you specific instructions
concerning discontinuing your medication, depending upon the medication. You may need
to be off these medications prior to your procedure. A list of medications which need to
be stopped before any procedures is enclosed.
4. Your other prescribed medications should be taken as usual with a small sip of water on
the day of your injection.
5. Since most of our injections are done with sedation, you need to have an adult with you to
drive you home. (YOU will not be allowed to have the procedure and take public
transportation)
6. Xrays will be taken during your procedure. If you think you may be pregnant or are not
sure, please call our office as soon as possible as we may need to re-schedule.
7. Wear comfortable, loose clothing and comfortable shoes to the Baylor Center for Pain
Management. Please leave valuables at home or with a family member.
8. Please refrain from use of perfume and lotions with fragrances on the day of the
procedure.
9. If you arrive late for you appointment, you may be rescheduled. If you must cancel your
appointment, please call our office 24 hours prior to your appointment and we will be
happy to reschedule you.
Please call 972-231-1591, for questions or cancellations.
Thank you for choosing Baylor Center for Pain Management.