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 PAGE 9 OF 10 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. PAGE 10 OF 10 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: ___________