The Ajax Anesthesia Pain Clinic
Kirit Patel MD FRCPC
Kevin Smith MD FRCPC
95 Bayly Street West, # 402
Ajax, ON L1S 7K8
Tel 905 427-3900
Welcome to our clinic,
You have been referred for the assessment and possible treatment of a particular pain condition. We are Anesthesiologists
who have a special interest in the assessment and treatment of primarily neck and back pain using specialized injections.
There are other conditions we assess as well. For more information, please refer to our website via
www.mydoctor.ca/ajaxpainclinic.
In order to process the referral and book a consultation, we ask you to complete the following:
1.
2.
3.
4.
5.
6.
Ensure you have a Family Doctor or primary treating physician.
Print off this package.
Complete the Pain Questionnaire as fully as possible.
Complete the insurance information form, only if you have an open accident-benefit claim.
Read and sign the Office Policy for Uninsured Services.
Mail or drop off the entire package at the above address.
You will then be called to set up an appointment for consultation with one of us. Unless there is a specific request, we
usually book consults with the first Physician available.
If you would like an earlier assessment and treatment, ask about our Osteopathic colleague, Dr. Gennady Vaserbakh, PhD.
He offers a unique and special type of treatment that can often be started prior to your initial consultation with us.
We look forward to meeting you.
Sincerely,
Dr. Kirit Patel & Dr. Kevin Smith
1
The Ajax Anesthesia Pain Clinic
Kirit Patel MD FRCPC
Kevin Smith MD FRCPC
95 Bayly Street West, # 402
Ajax, ON L1S 7K8
Tel 905 427-3900
Pain Evaluation Questionnaire
To help us better understand your current situation, please complete the following questionnaire as fully as possible.
Please mail or drop off at the address above as soon as you are finished to get an appointment.
TODAY’S DATE:
HEALTH CARD #:
_________________ NAME: ____________________________________________________
Year/Month/Day
First
Middle
Last
_________________________ WSIB/WCB #: ________________________________________
Is your pain related to an accident?
Yes
No If yes, is your insurance claim still open?
If yes, please fill in the insurance information form on page 4 and return with this questionnaire.
Are you involved in any legal action in regard to the accident or injury?
DATE OF BIRTH:
______________ Age: ______ SEX:
Year/Month/Day
ADDRESS:
Male
Yes
Yes
No
No
Female HEIGHT: ______WEIGHT: _______
In years
______________________________________________________________________________
______________________________________________________________________________
City
Province
Postal Code
TELEPHONE: _____________________________________________________________________________________
Home
Work
Cellular
FAMILY PHYSICIAN:
Dr. ______________ Phone: ___________________Fax: _______________________
REFERRING PHYSICIAN:
1.
2.
Dr. ______________
Phone: ___________________Fax:_______________________
a)
b)
c)
d)
When and how did you current pain problem start? ___________________________________________
When the pain first started, how did it start?
Gradually
Suddenly
Has your pain changed since it began?
No change
Decreased
Increased
If you have more than one type of pain, list them in order from worst to least:
_____________________________________________________________________________________
Location of pain: Please mark an “X” on the drawings where you feel pain.
3.
Please circle a number to indicate how much of the time you were in pain during the past 2 weeks:
0
1
2
3
4
5
6
7
8
9
10
Not at all
All of the time
4.
On the following pain scales, 0 means no pain and 10 means the most excruciating pain possible.
a)
Out of 10, how bad was your worst pain over the past two weeks:
0
1
2
3
4
5
6
7
8
9
10
No Pain
Worst pain imaginable
2
b)
c)
5.
Out of 10, how bad was your lowest/least pain over the past two weeks:
0
1
2
3
4
5
6
7
8
9
No Pain
10
Worst pain imaginable
Please rate your average pain score over the past two weeks:
0
1
2
3
4
5
6
7
No Pain
10
Worst pain imaginable
8
9
Place an X beside the words that describe your pain. Only fill in the columns that are relevant to your pain.
Back pain
Neck pain
Headache
Shoulder pain
Other:
Sharp
Shooting
Stabbing
Throbbing
Aching
Heavy/tight
Hot, burning
Cramping
6.
Describe everything that aggravates your pain: lifting bending walking standing sitting lying flat
climbing stairs
coughing sneezing looking up looking down turning the head thinking
reading stress sleep other: ______________
7.
Describe everything that relieves your pain, even mildly or temporarily: medication rest sleep
bending stretching physical therapy relaxation injections Other: ___________
8.
Which of the following symptoms do you experience? (Check only the ones that apply)
Numbness, where? ____________________
Pins and needles, where? _______________
Shooting pain down the arm(s), which one?
right
left
Shooting pain down the leg(s), which one?
right
left
Bowel incontinence
Urinary incontinence
9.
Please place a check beside ALL OF the specialists you have seen for pain:
Orthopedic/Neurosurgeon
Neurologist
Rheumatologist
Psychiatrist
Physiatrist
Anesthesiologist
Physio/Chiro
Massage
Acupuncture
Occupational therapist
Counselor
Psychologist
Other:__________
10.
Please check the tests you have had for your pain:
x-rays
CT
MRI
Bone scan
exercise
Nerve test/EMG
MEDICAL INFORMATION/SOCIAL & WORK HISTORY:
11.
Please list any major illnesses or hospitalizations you have had. Include smoking, depression, anxiety, problems
with blood pressure, heart, lungs, kidneys, brain and bone:____________________________________________
___________________________________________________________________________________________
12.
a)
Name
List ALL medications you are currently taking:
Dose
# per Name
day
Dose
# per
day
Name
Dose # per
day
3
b)
c)
List all medications you have taken and discontinued in the past for your pain problem, as well as the
reason for stopping:
_________________________________________________________________
List medical allergies: _________________________________________________________________
13.
14.
15.
Do you smoke cigarettes, cigars or a pipe?
Yes
No How many per day? ________
Since your pain began, has your weight changed?
Increased
Decreased
No change
Does your pain affect your sleep?
Yes
No
Sometimes
If NO, go to the next question; If SOMETIMES or YES, please answer the following:
a)
How many hours of sleep do you usually get each night? _______
b)
How many times do you wake up during the average night due to pain? ________
c)
Do you feel refreshed in the morning?
Usually
Not usually
d)
How many hours do you spend resting during the day DUE TO PAIN? ________
16.
Do you drink alcohol to control your pain?
Yes
No
Have you ever been assessed and/or treated for a drug or alcohol problem?
How many alcoholic drinks do you drink in a typical week? ______ drinks
Yes
No
_______ oz
17.
a) Does your pain affect your mood?
Yes
No
b) Check any terms that apply to your mood and overall condition:
Sad/depressed
Fatigued
Irritable
Angry/frustrated
Unable to cope
Poor memory
Unable to concentrate
Want to be alone
c) Are you currently in treatment for anxiety or depression?
Yes
No With whom? __________________
18.
Do you exercise regularly?
19.
Please check the box that best describes how difficult it has been for you to do each of the following activities in
the past two weeks:
Degree of difficulty:
Yes
No difficulty
No Describe: _____________________________________
Slight
Moderate
Extreme
Unable to do
a) Dress yourself
b) Wash yourself
c) Run errands and go shopping
d) Do chores such as vacuuming
e) Make meals
f) Participate in recreational activities
g) Socialize outside the house
20.
21.
Marital status: _____________ Members of your family: ____________________________________________
To what extent does the pain interfere with your relationship with your family life?
0
1
2
3
4
5
6
7
8
9
10
No Interference
Extensive interference
22.
23.
OCCUPATION: __________________ Describe your current work status: ______________________________
If NOT working,
a) How long has it been since you last worked? _____________ (months or years)
b) Are you not working because of pain?
Yes
No
c) Have you tried to return to work?
Yes
No
24.
Overall, to what extent do you feel the pain has interfered with your life?
0
1
2
3
4
5
6
7
8
9
10
Not at all
Extreme interference
________________________________________________________________________
THANK YOU
4
The Ajax Anesthesia Pain Clinic
Dr. Kirit Patel MD FRCPC
Dr. Kevin Smith MD FRCPC
95 Bayly St W, #402
Ajax, Ontario
L1S 7K8
Tel (905) 427-3900
NEW PATIENT MOTOR VEHICLE ACCIDENT INFORMATION FORM
This form needs to be completed if your pain is related to a specific motor
vehicle accident and there is an ongoing insurance claim. If your claim has
already settled, there is no need to complete this form.
Mail or drop off with the questionnaire to our office.
Insurance Company Name________________________________
Insurance Company Address______________________________
Date of Accident________________________________________
Policy Number__________________________________________
Claim Number__________________________________________
Policy Holder Name_____________________________________
Insurance Adjustor Name_________________________________
Insurance Adjustor Tel # ______________Fax#_______________
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The Ajax Anesthesia Pain Clinic
Kirit Patel MD FRCPC
Kevin Smith MD FRCPC
95 Bayly Street West, #402
Ajax, ON L1S 7K8
Tel (905) 427-3900
Fees for Uninsured Services
Dear Patient,
Although OHIP covers most of the costs of your health care needs, some services provided by your doctors are NOT
covered by OHIP. If you incur these charges and paying for them will be difficult, please let us know and a fee adjustment
can be considered. Your care will not be compromised if you are unable to pay for these uninsured services. Payment
can be made with cash on the day of service or prior to your next appointment and receipts are available upon request.
You have the option of paying for some of these uninsured services in the form of a ‘Block fee,’ covering a minimum
period of 3 months and a maximum period of 12 months, or for each service at the time that it is rendered.
In accordance with the Ontario Medical Association’s ‘The Physician’s Guide to Third Party and Other Uninsured
Services’ and the College of Physicians and Surgeons of Ontario Policy on ‘Uninsured Services and Block Fees’ (Policy
#6-00), the following charges will apply for services NOT paid by OHIP: (note: there is no fee unless you request any of
these services)
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Block Fee
$50.00
o for booked injections, includes 2 work- or school-related notes, 2 requests for renewals-of-prescription
over the telephone at patient’s request and one 5-minute phone advice.
Photocopies
$40.00 for pgs 1-5, $1.50 per pg thereafter
Phone advice at your request
$80.00 per 10 minutes
Phone prescription
$15.00
Sick note, back to work note
$15.00
Insurance forms
$50.00 to $150.00
Treatment plan
$100.00 to $200.00
Botox injections for pain
$150.00 to $350.00
Appointment Cancellation Policy
Considering our growing waiting list and in order to offer patients the earliest appointments possible, we deeply appreciate
your understanding and cooperation in keeping your appointments. We would ask you to give us at least 72 hours notice
if you cannot make your appointment so that we may offer your time to another patient. The following details our
cancellation policy:


If you cancel with less than 24 hours notice, there will be a $30 fee for follow-ups or $130 for
consultations or procedures. This fee will be payable prior to receiving another appointment.
Patients who repeatedly miss appointments may be discharged from the practice.
I have read and understand the information on this page. I agree to the above fee schedule for services not insured by
OHIP and understand that they may be changed with reasonable advanced notice.
Sincerely,
The Ajax Anesthesia Pain Clinic
______________________
Patient Signature
__________________
Date
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