NEW PATIENT REGISTRATION
Wayne E. Anderson, D.O.
A Medical Corporation
Chronic Intractable Pain Disorders
Headache & Facial Pain Disorders
Neurotoxin Therapy
We thank you for choosing our office. We believe in honesty, communication, and
transparency. For this reason, we may provide more written information than you
may find in other practices. Additionally, the US Healthcare system is changing and
part of the new US Healthcare system involves obtaining more information from
patients; as a result, this new patient registration form has become longer and more
detailed.
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.
In order to comply with new regulations, please be sure to bring a government photo
ID and your insurance card (if any) to each visit. For your safety, to avoid confusing
patients with similar names, we photograph patients; the photograph is used within
the electronic medical record and is not used for any purposes except for safety
purposes within the medical record.
Board Certified Neurology
American Board of Psychiatry & Neurology
Board Certified Pain Medicine
American Board of Psychiatry & Neurology
in association with the
American Board of Anesthesiology
Subspecialty Certified Headache Medicine
United Council for Neurological
Subspecialties
Qualified Medical Evaluator
Member of the
California Pacific Neuroscience Institute
45 Castro Street Suite 225
San Francisco CA 94114
415.558.8584 tel
415.513.4521 fax
www.wayneanderson.net
MEDICAL PRIVACY
“This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please review it carefully.”
We may provide reports to your primary care provider and other appropriate parties.
We do not provide your medical information to those not directly involved your
medical treatment unless specifically authorized by you. We do communicate your
information with your other health practitioners in order to coordinate care. The
Federal Government has determined that your health information may be provided
to others (even without your permission) for Treatment, Payment and Operations.
This includes sharing information with other physicians, providers and pharmacists,
reporting to your insurance company or to your workers’ compensation carrier, legal
services, training programs, quality improvement reviews and the like. We use
electronic medical records. These may include data from laboratories, hospitals and
other physicians. Because of the nature of these electronic systems, we are not able
to remove or hide certain information even if it comes from a different party. For
example, if you see another physician who also uses electronic medical records and
that physician enters “diabetes” as a diagnosis, your reports in this office also
automatically may include “diabetes” even if you did not tell us or want this to
appear in your chart. If you are a work comp patient, your reports may contain
additional information from other physicians, laboratories, hospitals, and other
parties, as above. Because we cannot remove medical information that comes from
other physicians, laboratories, hospitals, and other entities, if you authorize us to
send medical records to someone, you authorize us to send any and all information,
without restriction. Once you authorize us to discuss your medical information with
someone, you can revoke that authorization anytime. There are exceptions to the
privacy laws, and your medical information may be provided to others without your
consent for: (1) State of California reporting requirements; (2) Reporting
requirements for workers compensation claims; (3) Public health; (4) Health
oversight; (5) Legal proceedings; (6) Police investigations; (7) Any information on a
deceased patient; (8) Any information needed for organ donation; (9) Certain
research; (10) Any information needed by the government.
PAGE 2 OF 10
INFORMATION
First name:
Middle Initial:
Last name:
Birthdate:
Marital:
Sex:
S / M / D / W / PARTNER / REFUSE
Home phone:
Cell phone:
Address: For safety, we need your
street address, not a PO Box.
Emergency Contact:
Work phone:
Name
Relationship
Street
Telephone
Permission to let emergency
contact know specifics about your
condition? (see explanation to
right)
City
Zip
YES / NO
Email address:
@outlook.com @hotmail.com
@gmail.com
MALE / FEMALE
@yahoo.com
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.
We do not send private emails to your email
address, but after you sign up for the online
portal, you will receive email (or text)
appointment reminders.
To comply with new government guidelines, we use electronic prescriptions sent directly to your pharmacy. Please select
your local pharmacy and your mail order pharmacy (if any):
Local Pharmacy of your choice:
Pharmacy (Street and City) or (Telephone):
Mail Order Pharmacy of your choice:
CONSULTATION INFORMATION
Who referred you to our office?
Who is your regular doctor or provider?
(This is who you call for regular medical
check-ups)
Please circle the type of
consultation today:
INSURANCE PLAN / WORK COMP /
LEGAL CASE REFERRED BY ATTORNEY /
QME / NO INSURANCE / OTHER:
Is there a lawsuit planned or in
progress?
YES / NO
If work comp or legal, who is your
attorney?
For work comp patients, your carrier needs to
provide written authorization (not oral or
telephone permission) before we can see you.
Unfortunately, we are NOT able to obtain the
authorization for you. It must be provided by
your carrier based on a request from either
your current treating physician or your attorney.
TO BE IN COMPLIANCE WITH CURRENT IDENTITY THEFT RULES, PLEASE BRING YOUR INSURANCE CARD AND
GOVERNMENT ISSUED PHOTO ID TO EACH APPOINTMENT. WE ARE REQUIRED TO VERIFY YOUR IDENTITY.
PAGE 3 OF 10
CONDITION
THE ELECTRONIC MEDICAL RECORD SYSTEMS ASK FOR BASIC, SPECIFIC INFORMATION IN A SPECIFIC ORDER. ALTHOUGH
YOU MAY ATTACH ADDITIONAL INFORMATION TO YOUR NEW PATIENT FORM, PLEASE COMPLETE THE INFORMATION ON
THIS PAGE. PLEASE DO NOT WRITE “SEE ATTACHED.”
Where on the body is the problem? In addition to writing the body parts, please
mark the affected body parts on the picture to the right. 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 the accident or injury 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 ANY 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 or treat this problem.
EMG / NCV / MRI / CT / XRAY / SPINAL TAP / EEG / OTHER DIAGNOSTIC TESTS:
SURGERY / FACET INJECTIONS/EPIDURAL INJECTIONS/TRIGGER POINT INJ/BOTOX / SPINAL CORD STIMULATOR/TENS UNIT / MEDICATION /
MEDITATION / YOGA / GYM/ HOME EXERCISE/ACUPUNCTURE/PSYCHOLOGY/CHIROPRACTIC/OSTEOPATHIC MANUAL TREATMENT/OTHER:
Please tell us how severe your problem is, where 10 is the most severe anything could be:
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)
0 1 2 3 4 5 6 7 8 9 10
PAGE 4 OF 10
MEDICAL HISTORY
PLEASE CIRCLE THE APPROPRIATE WORDS OR PHRASES ON THE RIGHT FOR EACH CATEGORY. PLEASE WRITE IN ANY
CONDITIONS NOT LISTED.
Current medical conditions for
which you are currently being
treated or monitored:
NO ACTIVE PROBLEMS / ANXIETY / ASTHMA / DEPRESSION / DIABETES / ESOPHAGEAL REFLUX /
CHOLESTEROL / HIV / HIGH BLOOD PRESSURE / IRRITABLE BOWEL / MUSCLE SPASM / NECK PAIN /
BACK PAIN / HEADACHE / SUICIDAL THOUGHTS / OTHER:
Past medical conditions (major
things you had in the past but
no longer have):
NO SIGNIFICANT PAST PROBLEMS / ANXIETY / ASTHMA / DEPRESSION / DIABETES / HEART
PROBLEMS / HIGH BLOOD PRESSURE / HEPATITIS / HEAD INJURY / STROKE / SUICIDAL THOUGHTS /
OTHER:
Surgeries (please include the
approximate year of surgery):
NO SURGERIES / ABDOMEN / APPENDIX / C-SECTION / GALLBLADDER / LASIK / CATARACT / HERNIA
/ TONSILS / OTHER:
Family history (please include
things that run in the family):
ADOPTED – UNKNOWN / NO MAJOR PROBLEMS / ANXIETY / CANCER / CHRONIC PAIN / DEMENTIA
/ DEPRESSION / DIABETES / CHOLESTEROL / HEADACHES / HEART DISEASE / BOWEL PROBLEMS /
PARKINSONISM / STROKE / OTHER:
Social history:
Alcohol NONE / 14 OR FEWER PER WEEK / MORE THAN 14 PER WEEK
NEED TO CUT DOWN / OTHERS CRITICIZE / FEEL GUILTY ABOUT IT / DRINK BEFORE NOON
Alcohol is not considered safe with medications prescribed in this practice. If you do not
wish to stop alcohol completely to use medications, please discuss before having alcohol.
Illicit drugs NONE / FORMER / CURRENT (EXPLAIN):
Smoking CURRENT / FORMER / NEVER
Abuse PHYSICAL ABUSE IN PAST / PHYSICAL ABUSE CURRENTLY
Home ABLE TO TAKE CARE OF SELF-CARE / HAVE CARE GIVER
Work WORKING FULL TIME / WORKING PART TIME / VOLUNTEERING / PERMANENTLY DISABLED /
TEMPORARILY DISABLED / OTHER:
OCCUPATION: (please write)
Review of systems: THIS IS A LIST OF YOUR POSSIBLE CURRENT SYMPTOMS AT THIS EXACT TIME, NOT A LIST OF
CONDITIONS THAT YOU MAY HAVE. For example, if you have asthma, you would list ASTHMA above under current medical
conditions. If you are not having asthma problems today, you would not circle “wheezing” on the list below. But, if you ARE
wheezing today, you would circle “wheezing” on the list below. Please circle any conditions that you are experiencing
currently:
ENERGY / SWEATING / BLEEDING / WEIGHT CHANGES / WORST HEADACHE OF LIFE / SINUS / STIFF
PAIN (WHERE:
)
NECK / MUSCLE SPASM / DOUBLE VISION / SENSITIVE TO LIGHT / VISION PROBLEMS / EYELID DROOP
DISCHARGE (WHERE:
)
/ HEARING PROBLEMS / RINGING / HOARSENESS / CHOKING / CAN’T SWALLOW / DENTAL ISSUE /
BAD TASTE / CAN’T TALK PROPERLY / WRONG HEARTBEAT / CONGESTED / SHORT OF BREATH /
LUMPS (WHERE:
)
COUGHING / WHEEZING / APPETITE PROBLEM / DIFFICULTY SWALLOWING / HEARTBURN / NAUSEA /
LESIONS (WHERE:
)
DIARRHEA / CONSTIPATION / CAN’T CONTROL BOWELS-INCONTINENT / BLOOD / ABNORMAL URINE
SORES (WHERE:
)
/ CAN’T CONTROL URINE / PREGNANT / TRYING TO BECOME PREGNANT /WATER INTAKE / SWEATING
/ HOT FLASHES / FEEL WEAK / SEXUAL DIFFICULTY / BRUISING / STIFFNESS IN BODY PART / CLICKING
SWELLING (WHERE:
)
JOINT / GRINDING JOINT / CRAMPS / MUSCLES SHRINKING / DIZZY / FAINTING / CONCENTRATION /
BLEEDING (WHERE:
)
MEMORY LOSS / CONVULSIONS / ABILITY TO SMELL / ABILITY TO TASTE / BALANCE / COORDINATION
/ NEW OR UNEXPLAINED WEAKNESS / NEW OR UNEXPLAINED SENSORY LOSS / MOOD / SLEEP /
BAD THOUGHTS / DANGEROUS THOUGHTS /SKIN SENSITIVITY / FINGERNAIL OR HAIR ISSUES / OTHER:
PAGE 5 OF 10
MEDICATION HISTORY
Allergies: Please list any medications or substances you are either allergic to or cannot tolerate. Please also list the reason why
you cannot use the medication:
Current medications: Please list your current prescription medications, over the counter 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
Example: Aspirin
81mg
1 pill daily
Example: Vicodin
5/500
1 every 4 hrs if needed
If as needed, total in a day
Average 3 per day
Purpose
Prescriber
Prevent heart attack
Dr. John Doe
Knee pain
Dr. Jane Doe
1
2
3
4
5
6
7
8
9
Past medications: Although it may be difficult to remember things that you have tried for this condition, it is important that
you do your best. Knowing what was tried and why it is no longer used can be helpful to determine what types of medications
are appropriate and, obviously, to avoid retrying something that caused problems.
Prior medication
How long taken
Why no longer used
Example: aspirin 81mg
Every day for 3 years
Caused stomach bleeding
STANDARDIZED QUESTIONNAIRES
Please read this carefully. The following questionnaires are not written by us. They are standard questionnaires used to help
validate your condition and your responses are especially important in work comp cases and legal cases. The questionnaires
are not valid if you skip or change any questions. Therefore, please answer each question to the best of your ability, choosing
the closest answer if there is no exact answer. Please note that you might not need to answer each questionnaire (see the top
of each questionnaire).
Once again, the questionnaires are not valid if you skip any questions or change any answers. Please select the best match,
even if not exact.
PAGE 6 OF 10
HEADACHE PATIENTS ONLY: PLEASE COMPLETE THE FOLLOWING SECTION
On how many days in the last 3 months did you miss work or school because of your headaches?
(IF YOU DO NOT WORK OR GO TO SCHOOL, THE ANSWER IS ZERO)
How many days in the last 3 months was your productivity at work or school reduced by half or
more because of your headaches? (DO NOT INCLUDE DAYS COUNTED IN QUESTION 1.)
On how many days in the last 3 months did you not do household work (such as housework,
home maintenance, shopping, caring for children and relatives) because of your headaches?
How many days in the last 3 months was your productivity in household work reduced by half of
more because of your headaches? (DO NOT INCLUDE DAYS COUNTED IN QUESTION 3.)
On how many days in the last 3 months did you miss family, social or leisure activities because of
your headaches?
TOTAL OF NUMBERS:
CHRONIC PAIN PATIENTS ONLY: PLEASE COMPLETE THE FOLLOWING SECTION
Please circle a number for each of the pain words below. 0=don’t have it, 1=some, 2=more, 3=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 Sickening
DISABILITY, LAWSUIT, QME/AME, AND LEGAL CASES ONLY: PLEASE COMPLETE THE FOLLOWING SECTION
For each question below, please choose a number from zero to ten (0-10) to let us know how much the pain affects your
ability. For convenience, we have provided examples of what a ten would represent.
Does your pain …
Example of ten (10)
…interfere with your normal work inside and outside the home?
0 1 2 3 4 5 6 7 8 9 10
Can’t work at all
…interfere with personal care?
0 1 2 3 4 5 6 7 8 9 10
Need help with bathroom
…interfere with traveling?
0 1 2 3 4 5 6 7 8 9 10
See doctors only
…affect your ability to sit or stand?
0 1 2 3 4 5 6 7 8 9 10
Lay down always
…affect your ability to lift objects off the floor, bend, stoop, or squat?
0 1 2 3 4 5 6 7 8 9 10
Cannot do at all, ever
…affect your ability to lift overhead, grasp objects, or reach for things?
0 1 2 3 4 5 6 7 8 9 10
Cannot do at all, ever
…affect your ability to walk or run?
0 1 2 3 4 5 6 7 8 9 10
In wheelchair only
…force you to see doctors much more than before your pain began?
0 1 2 3 4 5 6 7 8 9 10
See doctors every week
…interfere with your ability to see the people who are important to you
as much as you would like?
0 1 2 3 4 5 6 7 8 9 10
Never see people who are
important to me
0 1 2 3 4 5 6 7 8 9 10
Can’t do any activities that
are fun, ever
0 1 2 3 4 5 6 7 8 9 10
Lost ALL income
0 1 2 3 4 5 6 7 8 9 10
Every day
0 1 2 3 4 5 6 7 8 9 10
Need help with most
everything all the time
0 1 2 3 4 5 6 7 8 9 10
Severe depression
0 1 2 3 4 5 6 7 8 9 10
Severe emotional
problems
…interfere with recreational activities and hobbies that are important to
you?
Has your income declined since your pain began (because of the pain)?
Do you choose to take pain medication every day to control your pain?
Do you need the help of your family and friends to complete everyday
tasks because of your pain?
Do you now feel more depressed, tense, or anxious than before your pain
began?
Do the emotional problems caused by your pain interfere with your
family, social or work activities?
PAGE 7 OF 10
DISABILITY, LAWSUIT, QME/AME, AND LEGAL CASES ONLY: PLEASE COMPLETE THE FOLLOWING SECTION
For each of the ten (10) lines below, please circle the one (1) phrase that best describes your situation. It is understood that
your situation may not be exactly like the phrases below, but please choose the one phrase in each line that is the closest to
your exact situation. Please do not change any questions or skip any questions or the questionnaire will not be valid.
PAIN IS BAD BUT I
1
I can tolerate the
pain without
using pain killers
2
I can look after
myself normally
without extra
pain
3
I can lift heavy
weights without
extra pain
WEIGHTS BUT IT
GIVES EXTRA PAIN
4
Pain does not
prevent me
walking
PAIN PREVENTS
WALKING MORE
THAN 1 MILE
I can manage
heavy weights if
conveniently
positioned
Pain prevents me
walking more
than 0.5 miles
5
I can sit in any
chair as long as I
like
I CAN SIT IN A
SPECIAL CHAIR AS
LONG AS I LIKE
Pain prevents me
sitting more than
1 hour
6
I can stand as
long as I want
I STAND AS LONG
AS I WANT BUT
Pain prevents
standing for
more than 1 hour
WEIGHTS IF
CONVENIENTLY
POSITIONED
PAIN PREVENTS ME
WALKING MORE
THAN 0.25 MILES
PAIN PREVENTS ME
FROM SITTING
MORE THAN 0.5
HOURS
PAIN PREVENTS
STANDING FOR
MORE THAN 30MIN
Pain does not
prevent me from
sleeping well
I CAN SLEEP WELL
7
Even with pills I
have less than 6
hours sleep
EVEN WITH PILLS I
HAVE LESS THAN 4
HOURS SLEEP
MY SEX LIFE IS
Sex life nearly
normal but is
very painful
SEX LIFE IS
8
My sex life is
normal with no
extra pain
SEVERELY
RESTRICTED BY PAIN
9
My social life is
normal and gives
me no extra pain
Pain limits some
activities such as
dancing
PAIN KEEPS ME
FROM GOING OUT
AS OFTEN
10
I can travel
anywhere
ANYWHERE BUT
WITH EXTRA PAIN
Pain is bad but I
manage journeys
over 2 hours
I ONLY DO TRIPS OF
LESS THAN 1 HOUR
i
ii
iii
MANAGE
WITHOUT PAIN
KILLERS
I CAN LOOK AFTER
MYSELF
NORMALLY BUT IT
CAUSES EXTRA
PAIN
I CAN LIFT HEAVY
WITH EXTRA PAIN
ONLY BY TAKING
PILLS
NORMAL BUT
CAUSES EXTRA
PAIN
MY SOCIAL LIFE IS
NORMAL BUT
CAUSES EXTRA
PAIN
I CAN TRAVEL
Pain killers give
complete relief
from pain
PAIN KILLERS GIVE
It is painful to
look after myself
and I am slow
and careful
I NEED SOME HELP
BUT MANAGE MOST
OF MY PERSONAL
CARE
LIGHT OR MEDIUM
MODERATE RELIEF
FROM PAIN
Pain killers
give very little
relief from
pain
Pain killers have
no effect on the
pain
I need help
every day in
most aspects
of self-care
I do not get
dressed wash
with difficulty and
stay in bed
I can lift only
very light
weights
I cannot lift or
carry anything at
all
I can only walk
using a stick or
crutches
Pain prevents
sitting more
than 10
minutes
Can’t stand for
more than 10
min
Even with pills
I have less
than 2 hours
of sleep
Sex life is
nearly absent
because of
pain
I am in bed most
of the time and
crawl to the toilet
Pain prevents me
from sitting at all
Pain prevents me
from standing at
all
Pain prevents me
from sleeping at
all
Pain prevents any
sex life at all
Pain has
restricted me
to my home
I have no social
life at all because
of pain
I only do
necessary trips
under 30
minutes
iv
Pain prevents me
from traveling
except to the
doctor
v
THE FINE PRINT
Very often, people sign forms without reading them. However, we do believe the information presented below is very
important and we ask that you read the information carefully. Please do not skip it.
Second opinions: Patients do not need to be afraid to ask for a second opinion. If you would like a second opinion, we would be pleased to provide
a referral.
Physician–patient relationship: We have a transparent, honest, and direct type of practice. This philosophy works for most patients but not all. If
you find difficulty with this no–nonsense approach, we would be pleased to refer you to a different physician who might have a different practice
philosophy. This is your health and you need to be comfortable with your doctor’s style. Do not be afraid to ask for a new doctor if that is your
desire.
PAGE 8 OF 10
Emergency Situations: Any patient could experience a medical emergency at any time. If you believe you have a medical emergency, call 911 or go
to the nearest emergency room. Emergency situations can arise from your medical condition, a new medical condition, a medication, or any
treatment, such as surgery, stimulators, blocks, physical therapy, etc. There are many warnings of an emergency, such as ches t pain and
uncontrolled bleeding. Some neurological warning signs that may signal an emergency: •Worst headache ever in life •Double vision •Dysarthria
(trouble speaking, slurring words, words coming out wrong) •Dysphagia (trouble swallowing) • Weakness (trouble moving) • Sensory loss (trouble
feeling) •Incontinence (trouble with bladder or bowel control) •New or sudden pain (may signal many conditions).
Risks of Treatments, Procedures & Medications: Treatments are designed to provide benefit for your condition. However, treatments have risks.
Any procedure could result in an injury. Any physical activity could increase pain or cause structural or other damage to the body. Successful
treatment usually requires more than prescription medication; it requires proper physical activity, engagement, and lifestyle changes. In most cases,
the good or beneficial part of a treatment plan is obvious: the treatment is supposed to help the problem. The risks require more attention. Any
medication could interact with another; you must let each of your providers know all medications and supplements you use and about all health
conditions you have. All medications have side effects, some of them serious, including death. Almost every medication could cause sleepiness or
insomnia, dizziness, confusion, hallucinations, anxiety, panic, constipation or diarrhea, headache, chest pain, and nausea or vomiting. Any of these
conditions could predispose the patient to injury (such as dizziness causing the patient to fall down stairs). Itching can oc cur. Sometimes itching
occurs with a rash and that may herald an allergic reaction; you should let your practitioner know about the rash immediately. Many ca use a drop in
blood pressure, which could cause fainting, dizziness, stroke or other problems. Sometimes, medications cause effects that are not predictable.
Some of the medications have not been in existence long enough to determine what potential long-term side effects could occur. This practice does
not require the use of a medication. All treatments have both known and unknown risks. The occurrence of a side effect does not imply medical
negligence and the patient agrees to hold the physician and corporation harmless for the occurrence of an adverse effect. Pati ents accept the risks
and freely choose to use prescription medication(s) and/or engage in physical treatments and physical activities.
Pregnancy, planning, and breastfeeding: You must assume that no medication is safe during pregnancy or during breast-feeding. You must let us
know if you are planning pregnancy or are pregnant. Medications may interfere with birth control, resulting in an unplanned pregnancy. Many
neurological medications cause major birth defects.
Alcohol, illegal drugs and unknown herbals and supplements are not considered safe with the medications used in this practice. Although we
understand the social aspects of drinking alcohol and the reported potential health benefits of low-level use, if you drink alcohol, we must counsel
you to stop in order to use the medications typically prescribed.
If you use or are planning to use controlled substance medications for pain: In addition to addiction risks, there are additional risks—both legal
and medical—for those patients who use controlled substance prescriptions. Common side effects of controlled substance pain medications include
lack of energy, fatigue, mental clouding, nausea, sweating, constipation, itching, and sexual problems. Although nausea may i mprove with time,
constipation tends to continue. Diet is important. In many cases a laxative regimen is required. Although the risk is low, there is a chance of laxative
dependence. Patients who ignore the constipation may require surgical removal of part of the intestines; untreated, constipati on can be fatal.
Opioids affect hormone levels in men and women. They reduce sexual desire and sexual function. Pain medications may cause deafness. Opioid
pain medications significantly increase the risk of asthma attacks or similar lung problems. This potentially fatal effect ca n occur even in very low
doses. The decision to use opioids or other controlled substances is not to be taken lightly. There is a risk of addiction with the use of pa inkillers.
The risk appears low unless there is a family or personal history of addiction to drugs, tobacco, or alcohol. However, w e cannot guarantee that you
will not become addicted to your medication. No guarantees regarding safety or addiction are stated or implied. For those who receive controlled
substances such as pain medications, the need to comply with federal and state laws requires more frequent in-person visits with more extensive
documentation at each visit than one might have for other medical conditions. Also, the medications used may have greater ris k, including risk of
death. If you have chronic pain, you might be a candidate for opioids when prescribed by a physician for the treatment of pain. However you must
show responsibility for the medications. You must protect against loss, theft, or damage; you must keep them away from children, animals and
others. In order to justify the use of controlled substances legally, you should report (1) improved pain control, (2) increased function or increased
activities, (3) no serious side effects, and (4) no episodes of aberrancy or abuse (like running out of medication early). I f you are being seen for pain
management, you agree to drug testing for both prescribed drugs and illicit drugs at any time. The presence of illicit drugs on a drug test may
require us to change or stop certain treatments; use of any illicit drugs could result in death or other severe harm. You agree to use one and only
one physician for pain medication prescriptions and one and only one pharmacy for pain medication dispensing (with exceptions for surgery or
acute pain treated elsewhere, provided we are informed about such prescribing as soon as possible and provided that the other prescriber also is
informed about prescriptions received here). As guidelines, laws, and regulations change, patients will have more oversight for pain medication
prescriptions. The reason for the government regulations is patient safety (as you may know, there have been multiple deaths from abuse of pa in
medications). REMS is a “risk evaluation and mitigation strategy” and may involve signing a special medication consent and, in some cases, may
involve signing–up with the government to receive certain prescription medications. Please be aware that the California Office of the Attorne y
General keeps a list of your prescription medications dispensed from any pharmacy in California. Other states have similar programs. The CURES
profile, when obtained, becomes part of your permanent electronic medical record. The current opioid agreement update reflect s the growing
governmental oversight and is available as a separate, larger document; it is as follows: Opioid use for pain management is not required. There are
alternatives. Opioid pain medications are not the first treatments for chronic pain. I certify that I have used both non -opioid pain medications and
modalities such as exercise and/or other physical treatments before escalating to opioid medications. I am aware that the use of such medicine has
certain risks associated with it, including but not limited to: sleepiness or drowsiness, constipation, nausea, itching, vomi ting, dizziness, allergic
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reaction, slowing of breathing rate, death, slowing of reflexes or reaction time, physical dependence, tolerance to analgesia (a loss of pain
reduction), addiction, and the possibility that the medicines will not provide complete pain relief. I understand that the main treatment goal is to
improve my ability to function by reducing pain. In consideration of that goal and the fact that I am being given potent medi cation to help me reach
that goal, I agree to help myself by following better health habits: exercising, controlling my weight, and avoiding the use of alcohol and tobacco. I
understand that only by following a healthier lifestyle can I hope to have the most successful outcome to my pain management treatment. In
understand that the long-term advantages and disadvantages of chronic opioid use have not been determined and that treatment may change
while I am under Dr. Anderson’s care. I understand, accept, and agree that unknown risks may be associated with the long-term use of controlled
substances and that my physician will advise me as knowledge and training advances are made, and will make appropriate treatment changes. I also
know there may be other non-opioid options for my pain control. I agree to tell my doctor about all other medicine and treatments that I am
receiving. I will not request or accept controlled substance pain medications from any other physician or individual while I am receiving such
medications from Dr. Anderson. To do so may endanger my health and our physician-patient relationship. The only four exceptions are: medication
prescribed while I am admitted to a hospital, taken only during the hospitalization; medication prescribed by a surgeon immed iately after surgery
provided both Dr. Anderson and the surgeon are aware of the situation before the prescription occurs; medications prescribed in cases where a
patient may have two different types of insurance coverage and because of the two insurance plans, two different physicians m ust address chronic
pain, provided that both physicians are aware of the situation before the prescription occurs; medication refills provided by the patient’s primary
care practice in those rare cases where the medications were due but Dr. Anderson was unavailable, provided that both offices are aware of the
situation before the prescription occurs. I agree to keep all scheduled appointments. At each visit, Dr. Anderson will evaluate me for pain relief, side
effects, function, and abnormal behavior that may indicate addiction. I understand that evaluation may also include recommended lab work to
monitor my medication’s efficacy. I must keep Dr. Anderson fully informed of any changes, Emergency Room visits, lost or stolen medications, or any
other circumstances affecting my health and well-being. Dr. Anderson may refer me to another physician for a second opinion while I am receiving
controlled substances. I understand that if I do not obtain this second opinion, Dr. Anderson may discontinue my medications or refill them with a
tapering dose to discontinue my use of them. You have my permission to discuss my pain condition and my pain treatments with my spouse or
significant other. I understand that driving a motor vehicle may be hazardous while taking controlled substances and that it is my responsibility to
comply with the laws of this state and conduct myself safely while taking the medication prescribed. We do not implicitly or explicitly provide
permission to drive or to engage in dangerous activities. I will not be involved in activities that may be dangerous to me or to someone else if I feel
drowsy or am not thinking clearly. I am aware that even if I do not notice it, my reflexes and reaction time might still be s lowed. Such activities
include but are not limited to: using heavy equipment or operating a motor vehicle, working at unprotected heights, or being responsible for
another individual who is unable to care for himself or herself. We do not implicitly or explicitly provide permission to dri ve or to engage in
dangerous activities. I will take my personal medications as directed. I will not tamper with prescribed medications by cutting, crushing, or by any
other means altering the intended dose of medication. I will not take the medications by any other than the directed route of administration
(usually oral). I will not adjust the medications by myself. I will discuss with Dr. Anderson any change in dosage I feel I n eed at the next appointment.
I will not increase the dose or take an extra dose unless directly authorized to do so by Dr. Anderson. I will not hoard my medications. If I am doing
better and I am able to control my pain with fewer narcotics, I will inform Dr. Anderson. If I have lowered my dose, I will i nform Dr. Anderson. I am
responsible for keeping track of the amount of medications left on my prescription and I will plan ahead for arrangements to refill my prescriptions
in a timely manner so I will not run out of medications. If I run out of medications, I may go through withdrawal. I understa nd that I must make
necessary arrangement to alert Dr. Anderson of my need for a refill five (5) working days before they run out. If I fail to provide five (5) working days’
notice, I may not be able to receive the prescription in a timely manner and may undergo withdrawal. Medications wil l not be refilled early, even if
they have been lost or stolen. Medication refill requests made on Fridays, weekends, or holidays will not be honored absent s pecial circumstances. I
have been fully informed by Dr. Anderson regarding the potential psychological dependence on a controlled substance. I know that some persons
may develop a tolerance, which is the need to increase the dose of the medication to achieve the desired effect. I know that I may become
physically dependent on the medication. This will occur if I am on the medication for even just a few weeks; when I stop the medication I must do so
slowly and under medical supervision or I may have withdrawal symptoms. I understand that some rare situations may arise where one of my
healthcare practitioners may make the clinical decision that the use of controlled substance (narcotic) pain medication may be too dangerous to
continue, even long enough to taper off. In such cases, I understand that I may experience narcotic withdrawal. I understand that if I fail to comply
with the guidelines in this agreement and the information on my prescription labels; if I obtain narcotics elsewhere (even from a physician); if I use
illicit drugs; if I share narcotics with others; or if I alter a prescription, we may need to cease prescribing and our doctor-patient relationship may be
terminated.
What is Off-label Prescribing? The medications typically used in neurology and pain management often are not FDA approved for
use for neurology, pain, or headache. This means that although there is evidence to support their use, the medications were
invented—and tested for the FDA—for other purposes. This is “off-label” use. A hypothetical example is aspirin, originally invented
and “FDA-approved” for fever, but now used “off-label” to prevent heart attacks. The use of the medications off-label is common,
legal, ethical, and appropriate based on research and standard of care. Sometimes there is no drug that is FDA–approved for a
medical condition and therefore, any and all treatments would be considered off–label. For example, there is no government–
approved treatment for HIV neuropathy, and therefore any treatment for that condition would require medications invented and
approved for another purpose.
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Pharmacy Policy / Refills: Patients receive prescriptions and a number of refills to last until the next scheduled appointment. Except
for rare circumstances, refill requests are not required and pharmacy refill requests are not authorized. If a refill is required, patients
should contact the office (not the pharmacy) directly. Please remember that pharmacy refill requests are not authorized.
Driving & Machinery: Many neurological conditions and medications affect the ability to drive. Conditions such as Alzheimers,
Parkinsons, epilepsy, pain, arthritis or headache can impair the ability to operate a vehicle or operate machinery. You must assume
responsibility for your own behavior: patients are instructed not to drive or to operate any vehicle or dangerous machinery if there
is any impairment whatsoever whether related to the underlying disorder or to the medication intended to treat the underlying
disorder. If in doubt, do not drive. Patients who are impaired and choose to drive and who are pulled over by law enforcement
usually are charged with driving under the influence, with the same mandatory penalties associated with drunk driving. We are not
the DMV and we do not provide legal permission to drive or to operate machinery.
We believe in honesty and transparency. We accept many insurance plans and bill them as a courtesy to you. If your insurance
information is not correct or if your insurance company does not respond in 45 days, all charges become your responsibility. We do
NOT provide “not medically necessary” services. If an insurer denies payment because it is not a covered benefit, retroactively
rescinds payment or considers the service “not medically necessary” or “experimental” or some other non-reimbursable status, you
agree that you are financially responsible for those charges. For work comp patients, we need your carrier’s written permission to
see you. Your carrier by law must provide payment within 60 days for non-contested claims. If your carrier does not do so, we will no
longer be able to see you as a work comp patient.
Charges for non–medical services: Not all physician services are covered benefits. Some charges are billed directly to patients as
they are services that are not part of a typical physician medical visit. Examples include: forms, research, letters, copying records, and
other activities. There are missed appointment and procedure fees.
Risks, benefits, and alternatives: At each and every visit, the patient has the opportunity to ask further questions about the risks,
potential benefits, and alternatives to any and all treatment modalities and medications prescribed in this office above and beyond
the information presented in both written and oral form. There are alternatives to the treatments recommended or prescribed by
this office, even if some of the alternatives require the patient to see a different practitioner or obtain the services of another
physician elsewhere. Alternatives include physical modalities, psychotherapy, functional restoration programs, implantable spinal
cord stimulators, and so on. Each has its own risks and benefits.
Financial involvement with pharmaceutical and other medical companies: Dr. Anderson at times is a paid employee of certain
pharmaceutical, medical device or other medically–related companies for activities such as lecturing, research, and advisory board
activities. Because we believe in honesty and transparency, this information is posted in the office and is available at the website. Dr.
Anderson does not receive payment or kickback for prescribing any procedure, test, or medication. However, if patients would prefer
having a medication from a company that Dr. Anderson has NOT worked for in the past, this is fine. Please read the financial
disclosure posted in the office and at the website.
Limitations: Because the practice is limited to neurology, headache and pain management, we do require that patients have a
primary care provider to address routine medical issues and overall care. The primary care provider also is essential when Dr.
Anderson is unavailable. There is a neurologist physician on-call 24 hours per day. However, the current neurology call group does
not include a pain specialist other than Dr. Anderson. Thus, when Dr. Anderson is not on call for the neurology call group, pain
support is limited.
ACKNOWLEDGEMENT
Again, welcome. We understand that the above is a lot to read and fill out, but it is very important that we have as much information
as possible to help determine the treatment options. Likewise, it is very important that you know about our policies and procedures.
Because there is computer software that allows the reader to alter the text, your signature below indicates that you have read and
have accepted the information presented above in its original form, even if the reader has chosen to alter, omit, or add any content
to the information presented.
I have read and accepted the information in the section titled “The fine print” as presented without altering, omitting, or adding
any content.
Signature: ________________________________________ Date: ___________