Wayne E. Anderson, D.O., F.A.H.S
Chronic Intractable Pain Disorders
Headache & Facial Pain Disorders
Neurotoxin Therapy
First name: _____________________________ MI: ____ Last name: ___________________________
Today’s date: ____________________________________
Welcome! We thank you for choosing our office. Please be sure to review our practice philosophy at our website
www.wayneanderson.net to learn more about our honest and transparent style. We want to be honest: if the treatment plan
includes controlled substances, in order to meet legal and medical guidelines, we are NOT able to initiate controlled
substance treatment today. Guidelines ask us to receive and review certain medical and pharmacy records before prescribing
controlled substance pain medications.
Your information:
Birthdate: _________________
Safety information:
Address: For safety, we need your street address, not a
Marital: S / M / D / W / Partner / Refuse
P.O. Box.
Sex: Male / Female / Other
Street: ______________________________
Home phone: _______________
City: SF / Other: ____________________
Cell phone: _______________
Zip: _______________
Work phone: _______________
State: CA / Other:
Email address: _______________
@outlook.com / @gmail.com /
@hotmail.com / @yahoo.com /
@
Emergency contact information:
We use your email to help sign you up for the online portal.
We do not sell your email and we do not send private emails
to your email address. After you sign up for the online portal,
you will receive email (or text) appointment reminders if you
so choose. You also will have access to your medical record.
Phone: _______________
Your local pharmacy of choice (if you use a mail
order pharmacy, it should appear in the record once
your insurance plan is entered):
If you select “NO” we would still call your emergency contact
if we believed it were necessary for your safety, but we would
provide only general information such as “We are concerned
because we have not heard from your name. You are listed as
an emergency contact. Please contact your name to see if you
are okay.” This means that your emergency contact would
still know that you are seeing a doctor for some reason, even
if we do not disclose the specific reason.
Name of contact: _______________
Relationship: _______________
Walgreens/CVS/Safeway/Rite-Aid/Other: _________
Street:
City:
Phone:
Permission to let emergency contact know specifics
about your condition? Yes / No
Please provide the names of those involved in your healthcare so that we may complete your electronic profile. These may be
physicians, nurses, or even a family member who helps make medical decisions on your behalf. Please list who these persons
are and their specialty (or relationship if not a medical provider).
Medical provider / person
Specialty or relationship
Medical provider / person
Specialty or
relationship
Specialist / Attorney /
Other:
Who referred you to this office:
Attorney / physician /
other:
Other:
Primary medical provider for checkups
(REQUIRED):
MD / DO / NP / PA /
other:
Other:
Specialist / Attorney /
Other:
Other provider:
Psychology / Surgery /
other:
Other:
Specialist / Attorney /
Other:
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Consultation type today:
INSURANCE / WORK COMP / QME / LEGAL FROM ATTORNEY / CASH / OTHER:
Please tell us about the problem:
Where on the body is the problem? ____________________________
In addition to writing the body parts above, please mark the affected body parts
on the picture to the left. Please be sure to notice right and left so we can see
what side(s) the problem is on.
When did the problem begin? ______________________
How did it begin? (accident, injury, unknown, etc.) _____________
If an accident or injury, please describe how it happened:
How often does the problem occur?
If in episodes, how long do they last?
CONSTANT/INTERMITTENT/EPISODES/HOW OFTEN?
SECONDS/MINUTES/FEW HOURS/MANY HOURS/DAYS/CONSTANT
If the problem is headaches, on how many days in the past 1 month did you have a headache? ___________
If the problem is headaches, on how many days in the past 1 month did you use an abortive? ___________
If the problem is headaches, what is the usual abortive? TRIPTAN / EXCEDRIN / OPIOID / OTHER: ___________
Progression of problem:
What makes it worse:
What makes it better:
STAYING THE SAME / GETTING BETTER / GETTING WORSE?
UNKNOWN / STRESS / INCREASED ACTIVITY / OTHER:
UNKNOWN / MEDS / REST / ICE / HEAT / OTHER:
Please circle any words or phrases below that you associate with this problem.
Not all patients will have these problems.
WORSE WITH ACTIVITY/AVOID LOUD NOISES/AVOID BRIGHT LIGHTS/NAUSEA/VOMITING/SEEING FLASHING LIGHTS/NIGHTTIME/
TIGHT BAND/PULSATING/SPEECH PROBLEM / DIZZINESS /CHILLS/WAKES ME UP / SEX / ORGASM / MENSTRUAL RELATED/FEVER/
TEARING OR NOSE RUNNING/EYEBALL PAIN/ DOUBLE VISION / DEAFNESS / RINGING IN EARS /CAN’T WALK PROPERLY/CONFUSION/
PASSING OUT/BLINDNESS/TRUE WEAKNESS OR PARALYSIS/ FEELING OF WEAKNESS / NUMBNESS OR TINGLING IN PART(S) OF THE BODY/
THIS PROBLEM RUNS IN THE FAMILY / PRIOR HEAD INJURY / PRIOR BRAIN PROBLEM
Please circle any things below that you have done to diagnose this problem.
EMG / NCV / MRI / CT / XRAY / SPINAL TAP / EEG / OTHER DIAGNOSTIC TESTS:
Please tell us how severe your problem is, where 10 is the most severe anything could be:
At best with your current treatment:
0 1 2 3 4 5 6 7 8 9 10
On average with your current treatment:
0 1 2 3 4 5 6 7 8 9 10
At worse with your current treatment:
0 1 2 3 4 5 6 7 8 9 10
How severe is the problem in general?
MILD (HATE IT BUT CAN KEEP DOING THINGS) /
MODERATE (SLOWS DOWN THINGS I TRY TO DO) /
SEVERE (RESTRICTS MANY THINGS I TRY TO DO) /
VERY SEVERE (HAVE TO STOP EVERYTHING ELSE)
If the problem is pain, please circle a number circle a number for each of the pain words below.
(0=don’t have it, 1=describes my pain some, 2=more, 3=that word describes my pain a lot)
0123 Gnawing
0123 Splitting
0123 Burning
0123 Frightening
0123 Tender
0123 Throbbing
0123 Shooting
0123 Tiring
0123 Stabbing
0123 Cramping
0123 Heavy
0123 Cruel
0123 Aching
0123 Sharp
0123 Masterful
0123 Sickening
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Allergies: Please list any allergies or intolerances and what happened or happens.
Current medications: Please list current medications and supplements. You may attach a list if you like, but the
list must include all six (6) columns listed below.
Medication
Size
How taken
If as needed, total # in a day
Purpose
Prescriber
Example: Aspirin
Example: Vicodin
81mg
5/500
1 pill daily
1 every 4 hrs if needed
1 per day
Average 3 per day
Prevent heart attack
Knee pain
Dr. John Doe
Dr. Jane Doe
Past medications for this problem: Please list previously tried medications for this problem and what happened
when you tried those medications. Did they work? Did they cause problems?
Medication
Size
How taken
How long did you try it?
What happened?
Example: Aspirin
81mg
1 pill daily
Two weeks
Gave me upset stomach
Treatments for this problem: Please list current and past treatments for this problem. Please use the comment
column to let us know whether the treatment helps/helped, and what was good or bad about it.
Psychology & Adjunct Therapies
Surgical pain
treatment
Would like
Currently
Surgery
Facet injections
Epidural injections
Trigger point injections
Botox injections
Internal spinal cord stimulator
Internal pain pump
Psychology
Biofeedback
Meditation
TENS unit
H-wave unit
Physical therapy
Occupational therapy
Chiropractic
Osteopathic
Exercise
Gym
Acupuncture
Other treatments not listed above:
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In past
Comments
Your medical history: Please list any problems that you have, had, or run in the family. For family problems, please indicate
whether the problem is in your mother, father, sibling, grandparent, etc. For surgeries, please list the approximate year. For
example, if you have asthma, you would write asthma in “problems I currently have”. If you are wheezing now you would circle
“wheezing” in the “symptoms that I am currently experiencing at this moment” box. But, if you are not wheezing now, you
would not circle wheezing.
Problems that I
currently have
Problems that I
had in the past
Problems that
run in family
Surgeries that I had
What family member(s):
mother, father, sibling, etc.
Approx year of surgery
Symptoms that I am currently experiencing at this moment:
Pain (where):
Lesions (where):
Bleeding (where):
Discharge (where):
Sores (where):
Fever (temperature):
Lumps (where):
Swelling (where):
Fainting / new or unexplained weakness / new or unexplained sensory loss / worst headache of life / double
vision / can’t talk properly / can’t swallow / can’t control bladder or bowels / Energy / sweating / bleeding / weight
changes / sinus / stiff neck / muscle spasm / sensitive to light / vision problems / eyelid droop / hearing problems / ringing /
hoarseness / choking / dental issue / bad taste / wrong heartbeat / congested / short of breath / coughing / wheezing /
appetite problem / difficulty swallowing / heartburn / nausea / diarrhea / constipation / blood / abnormal urine / pregnant
/ trying to become pregnant / water intake / sweating / hot flashes / feel weak / sexual difficulty / bruising / stiffness in
body part / clicking joint / grinding joint / cramps / muscles shrinking / dizzy / concentration / memory loss / convulsions
/ ability to smell / ability to taste / balance / coordination / / mood / sleep / bad thoughts / dangerous thoughts /skin
sensitivity / fingernail or hair issues / other:
Your social history: Please provide us an honest response to the following questions. With your honest response we will be
better able to formulate an appropriate treatment plan. The questions asked are part of the normal medical history plus the
“Opioid Risk Tool” which is recommended for potential pain patients.
Alcohol use:
NONE / < 7 PER WEEK / < 14 PER WEEK / >14 PER WEEK / RECOVERING ALCOHOLIC /
NEED TO CUT DOWN / OTHERS CRITICIZE / FEEL GUILTY ABOUT IT / DRINK BEFORE NOON / OTHER:
Safety note: alcohol is not considered safe with most medications prescribed in this practice. If you do not wish
to stop alcohol to use medications, please discuss options with us before having alcohol.
Illicit drugs:
Tobacco:
Abuse:
Your home:
Your work:
Occupation:
NONE / FORMER PROBLEM / IN PROGRAM / CURRENT (EXPLAIN):
NEVER / CURRENT / PAST
NONE / ABUSE IN PAST / ABUSE CURRENTLY
ABLE TO TAKE CARE OF SELF-CARE / HAVE CARE-GIVER / NOT ABLE TO DO PERSONAL CARE
WORKING FULL TIME / PART TIME / VOLUNTEERING / PERM DISABLED / TEMP DISABLED / OTHER:
___________________________________________
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Additional Information: In order to help reduce the use of paper and toner, we have removed several additional
pages from this registration paperwork. Instead of the prior 13 pages of forms, we have reduced this to 5 pages and
ask that you complete the additional pages only if they apply to you. Please look at this list to determine whether
the pages are required in your case.
Required if / for:
Persons being evaluated for a headache
or facial pain disorder in this office
Headache
information
(DOWNLOAD THE HEADACHE
INFORMATION DOCUMENT AT THE WEBSITE
WHERE YOU DOWNLOADED THIS
DOCUMENT)
Persons who are being evaluated for a
chronic pain condition in this office
Pain information
(DOWNLOAD THE PAIN INFORMATION
DOCUMENT AT THE WEBSITE WHERE YOU
DOWNLOADED THIS DOCUMENT)
Patient agreement
(printing optional,
see below)
Situations where we will be your
physician.



Treatments / prescriptions
Consultations
Procedures
Not required if / for:
Persons who are not being evaluated in
this office for a headache or facial pain
disorder
Persons who are not being evaluated in
this office for a chronic pain condition
Situations where we will not be your
physician.


QME
Legal evaluation requested by an
attorney
Most persons will need to complete the patient agreement. Because it is a lengthy document, you may
choose to read it without printing it by signing an acknowledgement below.
“I have read the document Patient Agreement thoroughly and completely but do not wish to print the
document. I have downloaded and saved the document for future reference. My signature below
certifies that I have read and accepted the information in the Patient Agreement as presented without
altering, omitting, or adding any content.”
Signature: ________________________________________________ Date: ______________________________
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