TF MEDICAL GROUP LLC

Authorization to obtain your healthcare records

Client/patient name *

Date of birth *

LAST 3 SSN *

CLICK HERE FOR TODAY'S DATE. YOU MUST CLICK AND USE THE CALENDAR * +

I authorize (please leave blank)

to disclose health information regarding the client referenced herein. I understand that the information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and that it is no longer protected by the federal privacy regulations.

Information to be disclosed to: tf (or Top Flight) Medical Group, P O Box 292796 Nashville, Tennessee 37229, whose phone contact number is 877.743.2646 and whose electronic mail addresses (email addresses) are: tfmedicalgroup@gmail.com, and whose fascimile is 877.472.3945 or 877.743.2646.

Purpose of use of this information: Assistance in providing medical care/continuity of medical care. I understand that unless I revoke the authorization earlier, this authorization will automatically expire 12 months after the date that this authorization is signed. Use of copies: A copy of this authorization may be utilized with the same effectiveness as an original.

I certify that I am the (please check one) *

Client/patient

authorized representative of the the client/patient

If authorized representative,relationship to the client/patient is

LEGIBLE signature of client/patient or representative *

clear

If signature is NOT the patient's, complete the following please

First and last name

Address

PRIMARY Contact phone number/ and or electronic mail (email) address *

WE DO NOT PRESCRIBE OPIOID MEDICATIONS FOR LONG-TERM MANAGEMENT

WELCOME TO TF MEDICAL GROUP. WE ARE EXCITED ABOUT THE OPPORTUNITY TO SERVE YOUR HEALTHCARE NEEDS. PLEASE TAKE TIME TO COMPLETE OUR PRE- APPOINTMENT FORM. DON'T FORGET TO PRESS THE SUBMIT BUTTON. (PLEASE NO PERIODS OR COMMAS OR OTHER PUNCTUATION MARKS. SEPARATE DATES BY SPACES)

PLEASE NOTE THAT WE WANT TO PROVIDE THE SAFEST AND MOST APPROPRIATE MEDICAL CARE AVAILABLE. IN ORDER TO DO SO, WE HAVE FOUND IT IMPORTANT TO HAVE CERTAIN POLICIES APPLICABLE TO ANY NEW CLIENT. WE WILL NOT BE ABLE TO SEE YOU IF YOU ARE USING ANY ILLEGAL DRUGS. YOU MUST BE ABLE TO PASS A URINE DRUG SCREENING TEST AT THE TIME OF YOUR FIRST VISIT WITH US. EXCEPTIONS: (If you have a prescription medication card and prescription for medicinal marijuana or if you are been prescribed medications which may contain cannabis)

WE DO NOT WRITE PRESCRIPTIONS FOR NARCOTIC OR ANY PAIN MEDICATIONS FOR MANAGEMENT OF CHRONIC NON-MALIGNANT PAIN ALSO, WE MUST HAVE YOUR APPROPRIATE MEDICAL RECORDS PRIOR TO WRITING ANY PRESCRIPTION MEDICATIONS AT ALL.

WE HOPE THAT YOU SHARE OUR ZERO TOLERANCE POLICY FOR ILLEGAL SUBSTANCES

HAVE YOU BEEN COMPLETELY VACCINATED AGAINST COVID-19 *

YES

NO

WHICH CITY IS THE CLINIC LOCATED IN THAT YOU ARE BEING SEEN AT FOR YOUR FIRST VISIT WITH US *

PLEASE READ THROUGH THE NEXT FEW PARAGRAPHS WHICH STATE MANY OF OUR IMPORTANT GROUP POLICIES. THEN, IF YOU AGREE, CHECK THE APPROPRIATE AREA (BOX). IF NOT, YOU CAN SIMPLY DISGARD THE ONLINE FORM:

IF THIS FORM IS NOT BEING COMPLETED 7-30 DAYS PRIOR TO YOUR SCHEDULED VISIT, PLEASE STOP HERE AND CONTACT OUR GROUP BEFORE YOU ATTEMPT TO COMPLETE THE FORM. AGAIN, THIS FORM SHOULD COMPLETED AT LEAST 7 DAYS AND NO MORE THAN 30 DAYS PRIOR TO YOUR FIRST APPOINTMENT WITH US. YOU WILL NEED SPECIAL AUTHORIZATION IN ORDER FOR THE FORM TO BE ACCEPTED FOR THIS VISIT. EVEN IF YOU COMPLETE THE FORM LATE, IT WILL NOT BE ACCEPTED WITHOUT AUTHORIZATION.

WE WOULD LIKE ALL PROSPECTIVE CHRONIC PAIN MANAGEMENT PATIENTS TO KNOW THAT WE DO REQUIRE A JOURNAL (PAIN DIARY) OF SOME SORT BE KEPT REGULARLY- PLEASE REVIEW THE INFORMATION AVAILABLE ON OUR WEBSITE IF YOU ARE NOT SATISFIED THAT YOU HAVE ENOUGH INFORMATION TO HELP YOU MAKE A DECISION ON A PROVIDER/PROGRAM IN THE PAIN MANAGEMENT AREA

PLEASE NOTE THAT WE WANT TO PROVIDE THE SAFEST AND MOST APPROPRIATE MEDICAL CARE AVAILABLE. IN ORDER TO DO SO, WE HAVE FOUND IT IMPORTANT TO HAVE CERTAIN POLICIES APPLICABLE TO ANY NEW CLIENT. WE WILL NOT BE ABLE TO SEE YOU IF YOU ARE USING ANY ILLEGAL DRUGS. YOU MUST BE ABLE TO PASS A URINE DRUG SCREENING TEST AT THE TIME OF YOUR FIRST VISIT WITH US. EXCEPTIONS: (If you have a valid prescription medication card and prescription for medicinal marijuana or if you are been prescribed medications which may contain cannabis).

WE DO NOT WRITE PRESCRIPTIONS FOR NARCOTIC OR ANY PAIN MEDICATIONS AT THE TIME OF YOUR FIRST VISIT WITH US. ALSO, WE MUST HAVE YOUR APPROPRIATE MEDICAL RECORDS PRIOR TO WRITING ANY PRESCRIPTION MEDICATIONS AT ALL.

BRING ALL CURRENT ACTIVE MEDICATIONS IN THEIR RESPECTIVE BOTTLES/PLANNERS TO THE INITIAL VISIT

We are NOT able to see clients who have not completed the intake process in the manner described-7 days prior to your visit. Also, patients who are being evaluated for our chronic pain program who fail the first toxicology (drug) screen, will NOT be eligible a trial of opioid (narcotic) management

WE DO NOT PROVIDE PRESCRIPTIONS FOR CHRONIC PAIN MANAGEMENT AT INITIAL VISITS. PLEASE NOTE: YOU MUST HAVE VALID STATE OF TENNESSEE IDENTIFICATION

We are NOT able to see clients who have not completed the intake process in the manner described- A MINIMUM OF 7 days prior to your visit and a MAXIMUM of 30 days prior to the first visit. Also, patients who are being evaluated for our chronic pain program who fail the first toxicology (drug) screen, will NOT be eligible for a trial of opioid (narcotic) management at all.

WE NOW REQUIRE THE COMPLETION OF A SECOND RELEASE OF INFORMATION FORM FOR NEW PATIENTS. PLEASE BE SURE TO COMPLETE THE INDIVIDUAL RELEASE OF INFORMATION FORM WHICH IS LOCATED ON OUR WEBSITE ( LOOK FOR RELEASE OF INFORMATION LINK ON THE HOME PAGE). THIS HELPS US TO BE MOST EFFICIENT IN ALL THINGS

WE DO NOT PROVIDE PRESCRIPTIONS FOR CHRONIC PAIN MANAGEMENT AT INITIAL VISITS. ALSO, WE DO NOT REPLACE ANY LOST OR STOLEN PRESCRIPTION MEDICATIONS AT ALL.

WE DO NOT REPLACE LOST OR STOLEN PRESCRIPTIONS OR MEDICATIONS *

YES HAVE REVIEWED AND UNDERSTAND THE ABOVE AND AGREE

WE DO NOT PRESCRIBE OPIOID MEDICATIONS FOR LONG-TERM MANAGEMENT

SOME THINGS ABOUT YOU

WHAT IS YOUR GOAL FOR TREATMENT/MANAGEMENT *

WHAT IS THE DATE OF YOUR APPOINTMENT (YOU MUST CLICK TO USE THE CALENDAR) +

LAST NAME *

FIRST TWO LETTERS *

M I

JR, SR, II, III, ETC

MALE OR FEMALE *

CITY AND STATE YOU RESIDE IN *

OPTIONAL: YOUR RACE

INSURANCE PROVIDER/COMPANY IF YOU HAVE ONE ( IF NONE TYPE "NA" ) *

INSURANCE SECONDARY (IF APPLICABLE)

INSURED'S PLACE OF EMPLOYMENT (IF NONE TYPE "NA") *

CITY AND STATE OF INSURED'S EMERGENCY CONTACT PERSON IF DIFFERENT THAN FROM THE CLIENT *

ARE YOU REGISTERED DISABLED ( YES OR NO ) *

WHAT IS YOUR CURRENT LEGAL MARITAL STATUS *

NAME ON INSURANCE CARD *

WHO IS YOUR PRIMARY CARE PHYSICIAN ( IF NONE THEN TYPE "NA") *

WHERE IS YOUR PRIMARY CARE PROVIDER'S OFFICE *

WHAT IS YOUR PRIMARY CARE PROVIDER'S OFFICE NUMBER

EMERGENCY CONTACT (FIRST INITIAL) AND LAST NAME AND CONTACT NUMBER *

DATE THIS FORM IS BEING COMPLETED +

WHO REFERRED YOU *

RT OR LT HANDED *

HEIGHT *

NUMBER OF CHILDREN (IF NONE THEN NA) *

WHICH OF THE FOLLOWING DO YOU USE OR HAVE ACCESS TO *

PLEASE NOTE THAT BY CHECKING THE BOX "YES" I, THE CLIENT DO AUTHORIZE THE RELEASE OF ANY MEDICAL OF OTHER INFORMATION NECESSARY TO PROCESS THIS CASE OR CLAIM. I REQUEST ALSO, AND AUTHORIZE PAYMENT OF MEDICAL OR GOVERNMENT BENEFITS TO MY TREATING PROVIDER HERE, WHO ACCEPTS ASSIGNMENT. I AUTHORIZE ANY TREATMENT PROCEDURE OR LAB WORK DEEMED NECESSARY BY THE TREATING PROVIDER OR STAFF MEMBER. I AGREE TO BE PERSONALLY RESPONSIBLE FOR ANY AND ALL CHARGES REGARDLESS OF WHETHER THEY ARE PAID BY INSURANCE; AND I AGREE TO PAY ANY COURT COST ASSOCIATED WITH THE COLLECTION OF MY ACCOUNT BALANCE. IF I DO NOT AGREE WITH THE ABOVE, THEN I WILL NOT COMPLETE THIS FORM AND WILL PLAN ON CANCELLING ANY PLANNED VISIT WITH THE PROVIDER OF CARE, UNTIL SOME AGREEMENT IS MADE OTHERWISE ON MY BEHALF, WHICH WILL SATISFY THE PROVIDER, PROVIDER'S GROUP, AND ANY POTENTIAL INSURER, PAYOR, AND MYSELF AS WELL. *

WE HOPE THAT YOU SHARE OUR ZERO TOLERANCE POLICY FOR ILLEGAL SUBSTANCES

PLEASE CAREFULLY DESCRIBE YOUR DAILY EXERCISE ROUTINE WHATSOEVER IT MAY BE *

WE DO NOT PRESCRIBE OPIOID MEDICATIONS FOR LONG-TERM MANAGEMENT

FIRST COMPLAINT THIS IS YOUR MAIN COMPLAINT

MANY OF OUR CLIENTS HAVE MORE THAN ONE (1) COMPLAINT. (EXAMPLES WOULD LOWER BACK PAIN AND UPPER BACK PAIN, OR BACK PAIN AND HIP PAIN, OR EVEN SHOULDER PAIN, NECK PAIN, AND RIGHT LEG WEAKNESS) SO, IF YOU HAVE MULTIPLE COMPLAINTS OR PROBLEMS, USE THE EXTRA SPACES PROVIDED TO LIST THEM AND GIVE US THE DETAILS

WHAT IS YOUR MAIN COMPLAINT *

HOW DID PROBLEM START *

HOW LONG *

WHAT MAKES IT WORSE *

DESCRIBE THE DISCOMFORT (SHARP, DULL, BURNING, ETC) *

DOES PAIN COME ON AT ANY PARTICULAR TIME/ IF SO WHEN *

IF THERE IS RADIATION OF YOUR PAIN WHERE IS IT TO MOSTLY ( IF NONE THEN TYPE NA ) *

DOES YOUR PAIN GO TO ONE SIDE MORE THAN OTHERS (LEFT OR RIGHT) OR NA/NO *

WHAT HELPS TO IMPROVE THIS PROBLEM/COMPLAINT *

HAVE YOU HAD ANY SURGERY RELATED TO YOUR COMPLAINT *

YES

NO

IF YOU HAD SURGERY RELATED TO YOUR COMPLAINT DID IT HELP

YES

NO

IF YOU HAVE HAD ANY SURGERY RELATED TO THIS CONDITION WHO DID IT AND WHEN AND WHERE WAS IT DONE. DID THE SURGERY HELP *

IF YOU HAVE HAD SURGERY RELATED TO YOUR COMPLAINT WHEN WAS IT DONE WHAT WAS DONE AND WHO DID IT

PAIN LEVEL 0-10 WITHOUT MEDICATION *

PAIN LEVEL WITH MEDICATION (IF NO MEDS THEN TYPE NA) *

SECOND COMPLAINT

WHAT IS YOUR 2ND COMPLAINT

HOW DID PROBLEM START

HOW LONG

WHAT MAKES IT WORSE

DESCRIBE THE DISCOMFORT (SHARP, DULL, BURNING, ETC)

DOES PAIN COME ON AT ANY PARTICULAR TIME/ IF SO WHEN

IF THERE IS RADIATION OF YOUR PAIN WHERE IS IT TO MOSTLY ( IF NONE THEN TYPE NA )

DOES YOUR PAIN GO TO ONE SIDE MORE THAN OTHERS (LEFT OR RIGHT) OR NA/NO

WHAT HELPS TO IMRPOVE YOUR COMPLAINT

HAVE YOU HAD ANY SURGERY RELATED TO YOUR COMPLAINT

YES

NO

IF YOU HAD SURGERY RELATED TO YOUR COMPLAINT DID IT HELP

YES

NO

IF YOU HAVE HAD SURGERY RELATED TO YOUR COMPLAINT WHEN WAS IT DONE WHAT WAS DONE AND WHO DID IT

PAIN LEVEL 0-10 WITHOUT MEDICATION

PAIN LEVEL WITH MEDICATION (IF NO MEDS THEN TYPE NA)

THIRD COMPLAINT

WHAT IS YOUR 3RD COMPLAINT

HOW DID PROBLEM START

HOW LONG

WHAT MAKES IT WORSE

DESCRIBE THE DISCOMFORT (SHARP, DULL, BURNING, ETC)

DOES PAIN COME ON AT ANY PARTICULAR TIME/ IF SO WHEN

IF THERE IS RADIATION OF YOUR PAIN WHERE IS IT TO MOSTLY ( IF NONE THEN TYPE NA )

DOES YOUR PAIN GO TO ONE SIDE MORE THAN OTHERS (LEFT OR RIGHT), OR NA/NO

WHAT HELPS TO IMPROVE THIS PROBLEM/COMPLAINT

HAVE YOU HAD ANY SURGERY RELATED TO YOUR COMPLAINT *

YES

NO

IF YOU HAD SURGERY RELATED TO YOUR COMPLAINT DID IT HELP

YES

NO

IF YOU HAVE HAD SURGERY RELATED TO YOUR COMPLAINT WHEN WAS IT DONE WHAT WAS DONE AND WHO DID IT

PAIN LEVEL 0-10 WITHOUT MEDICATION

PAIN LEVEL WITH MEDICATION (IF NO MEDS THEN TYPE NA)

25Health and Safety_doctorteam01_l_000000_FFFFFF.jpg

YOU AND YOUR FAMILY'S MEDICAL HISTORY

YOUR AND YOUR FAMILY'S MEDICAL AND SURGICAL PAST HISTORY

LIST ALL MEDICAL PROBLEMS/DIAGNOSES IF NONE TYPE NONE * 🛈

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FROM WHO/WHERE CAN WE OBTAIN YOUR PREVIOUS RECORDS *

FROM WHO/WHERE CAN WE OBTAIN YOUR PREVIOUS IMAGING REPORTS-X RAY, CT SCANS, MRI SCANS, ETC (IF NONE- TYPE NA) *

IF YOU HAVE A LIST OF YOUR OTHER MEDICAL OR SURGICAL HISTORY PLEASE ATTACH 🛈

LIST ANY SURGERY THAT YOU HAVE EVER HAD IF NOT ON ATTACHED LIST

IF YOU HAVE OTHER MEDICAL SPECIALISTS YOU MAY ATTACH NAMES AND LOCATIONS

IF YOU HAVE A DENTIST PLEASE PLACE THE NAME AND PRACTICE LOCATION HERE. IF NOT PLEASE KEY IN NA OR NONE *

IF YOU HAVE A MEDICATION LIST ATTACH THE ENTIRE LIST OR YOU CAN ENTER EACH BELOW

IF YOU HAVE SEEN OTHER PRIMARY CARE PROVIDERS WITHIN THE LAST 12 MONTHS PLEASE LIST

IF YOU HAVE NOT ATTACHED A MEDICATION, PLEASE LIST EACH OF YOUR CURRENT
PRESCRIBED MEDICATIONS/ VITAMINS SUPPLEMENTS AND INCLUDE STRENGTH AND DOSE.
YOU CAN ALSO ATTACH A LIST. KEY IN N/A IF NONE. IF YOU ARE ATTACHING A LIST ELECTRONICALLY TO
THIS FORM THEN INDICATE THAT HERE *

PLEASE ENTER NA (OR NOT TAKING) IF THIS QUESTION DOES NOT APPLY TO YOU. IF YOU ARE CURRENTLY TAKING A BENZODIAZEPINE CLASS MEDICATION, IS IT BEING PRESCRIBED BY A MENTAL HEALTH SPECIALIST *

LIST ALL FAMILY MEDICAL PROBLEMS ON FATHER'S SIDE OF FAMILY (IE: DIABETES, HEART ATTACK)

LIST ALL FAMILY MEDICAL PROBLEMS ON MOTHER'S SIDE OF FAMILY (IE: DIABETES, HEART ATTACK)

ALLERGIES

LIST ANY KNOWN DRUG/MEDICATION ALLERGIES (AND WHAT HAPPENS?) *

MIND SPIRITUAL WELL BEING

IF YOU HAVE ANY PSYCHOLOGICAL DIAGNOSES LIST THEM ENTER N/A IF NONE *

LIST/ COMMENT ON ANY SPECIFIC PROBLEMS CAUSING INCREASE IN DAILY STRESS

NAME OF PSYCHOLOGICAL SPECIALIST AND HOW OFTEN YOU HAVE APPOINTMENTS (IF NONE THEN PLEASE ENTER NA) *

NAME AND LOCATION OF YOUR PSYCHOLOGICAL CENTER IF APPLICABLE

SOCIAL HISTORY

HIGHEST LEVEL OF EDUCATION COMPLETED *

LIST ALL LANGUAGES THAT YOU SPEAK HERE *

TYPE OF WORK PREVIOUSLY DONE (IF ANY) IF NONE THEN TYPE NA OR NONE *

CURRENTLY WORKING (YES/NO) *

IF WORKING DESCRIBE WHAT YOU DO/ If NOT working describe previous types of work done and if NEVER worked key in the word never *

0/255 words

IS HOME STABLE *

EVER FAILED URINE OR ORAL DRUG TEST *

USE ALCOHOL *

ILLEGAL DRUGS *

USE TOBACCO *

IF YOU USE TOBACCO, WHAT FORM OF IT DO YOU USE ( SMOKE, CHEW, ETC)

IF YOU USE TOBACCO PRODUCTS, HOW MUCH DO YOU USE DAILY

CHECK EACH YOU'VE HAD TREATMENT FOR OR BEEN TOLD YOU NEEDED TREATMENT, N/A IF NONE *

ALCOHOL ABUSE

ILLEGAL DRUG ABUSE

PRESCRIPTION DRUG ABUSE

N/A

IF YOU HAVE EVER USED ILLEGAL DRUGS LIST HERE THE NAMES (IF NOT INSERT NA OR NONE) *

IF USED DRUG/ ALCOHOL USE NAME THE DRUG/ SPECIFY ALCOHOL TYPE AND WHEN LAST USED AND AMOUNT

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CHECK THE THINGS THAT YOU CAN DO FOR YOURSELF *

IF YOU HAVE EVER BEEN TO ANY PAIN MANAGEMENT/TREATMENT CENTER OR CLINIC NAME IT/THEM HERE. 2) TELL US THE LOCATION AND WHEN YOU WERE LAST THERE 3) WHY YOU ARE NO LONGER THERE. IF YOU HAVE NEVER BEEN IN A FORMAL PAIN MANAGEMENT CENTER OR CLINIC THEN TYPE NA OR NONE. (WE WILL CHECK WITH PREVIOUSLY ATTENDED CLINICS AND CONFIRM REASON FOR LEAVING THEM) *

IF YOU HAVE A LIST OF PAST PAIN SPECIALISTS YOU MAY ENTER OR ATTACH LIST HERE 🛈

NAME ALL PAIN MANAGEMENT GROUPS (OR SPECIFIC LOCATIONS - CITY/STATE) SEEN IN THE PAST 🛈

HAVE YOU BEEN RELEASED FROM PREVIOUS PAIN CLINIC IF YOU ATTENDED ONE (IF NONE CHOOSE NA) *

IF YOU WERE RELEASED FROM A PAIN CLINIC PREVIOUSLY, PLEASE TELL US WHEN AND WHY- IF SAME AS ABOVE THEN TYPE "SAME AS ABOVE" or IF None previously attended pelase enter "NA". (WE WILL CHECK WITH PREVIOUSLY ATTENDED CLINICS AND CONFIRM REASON FOR LEAVING THEM)

HAVE YOU EVER BEEN CONVICTED OF A FELONY *

HAVE YOU EVER ATTEMPTED SUICIDE *

YOUR PREVIOUS TREATMENT FOR YOUR COMPLAINTS

WHICH TREATMENTS/THERAPY FOR YOUR COMPLAINT HAVE YOU HAD

IF YOU HAD PHYSICAL THERAPY PREVIOUSLY FOR THE SAME PROBLEMS THAT YOU ARE HERE TO SEE US FOR, THEN WHERE DID YOU GO SPECIFICALLY 2) WHEN DID YOU GO 3) WHERE DID YOU GO 4) DID IT HELP 5) DID YOU FINISH THE COURSE 6) ARE YOU CONTINUING TO DO THE HOME EXERCISES THAT YOU MAY HAVE BEEN GIVEN. PLEASE ANSWER COMPLETELY. IF YOU HAVE NOT BEEN TO PHYSICAL THERAPY FOR YOUR COMPLAINTS THEN KEY IN "NA" *

WHICH OF THE ABOVE HELPED YOU IF NONE TYPE NONE *

WHICH OF THE ABOVE DID YOU HAVE A BAD REACTION TO IF NONE TYPE NONE *

WHICH MEDICATIONS/REMEDIES HAVE YOU TAKEN TO HELP PAIN RELATED TO YOUR PROBLEM * 🛈

IF THERE IS SOME OTHER MEDICATION THAT YOU - HAVE TRIED THEN NAME OTHER MEDICATION(S) HERE

NAME ANY MEDICATION THAT HAS ACTUALLY SIGNIFICANTLY HELPED FOR ANY OF YOUR LISTED COMPLAINTS- IF NONE THEN STATE SO *

GENERAL SYSTEM REVIEW

TODAY DO YOU HAVE ANY NEW

Over the last two weeks, how often have you been bothered by any of the following problems- select one choice only

LITTLE INTEREST OR PLEASURE IN DOING THINGS *

NOT AT ALL	SEVERAL DAYS
MORE THAN HALF THE DAYS	NEARLY EVERY DAY

FEELING DOWN, DEPRESSED, OR HOPELESS *

NOT AT ALL	SEVERAL DAYS
MORE THAN HALF THE DAYS	NEARLY EVERY DAY

TROUBLE FALLING OR STAYING ASLEEP, OR SLEEPING TOO MUCH *

NOT AT ALL	SEVERAL DAYS
MORE THAN HALF THE DAYS	NEARLY EVERY DAY

FEELING TIRED OR HAVING LITTLE ENERGY *

NOT AT ALL	SEVERAL DAYS
MORE THAN HALF THE DAYS	NEARLY EVERY DAY

POOR APPETITE OR OVEREATING *

NOT AT ALL	SEVERAL DAYS
MORE THAN HALF THE DAYS	NEARLY EVERY DAY

FEELING BAD ABOUT YOURSELF - OR THAT YOU ARE A FAILURE OR HAVE LET YOURSELF OR YOUR FAMILY DOWN *

NOT AT ALL	SEVERAL DAYS
MORE THAN HALF THE DAYS	NEARLY EVERY DAY

TROUBLE CONCENTRATING ON THINGS, SUCH AS READING THE NEWSPAPER OR WATCHING TELEVISION *

NOT AT ALL	SEVERAL DAYS
MORE THAN HALF THE DAYS	NEARLY EVERY DAY

MOVING OR SPEAKING SO SLOWLY THAT OTHER PEOPLE COULD HAVE NOTICED? OR THE OPPOSITE-BEING FIDGETY OR RESTLESS THAT YOU HAVE BEEN MOVING AROUND A BIT MORE THAN USUAL *

NOT AT ALL	SEVERAL DAYS
MORE THAN HALF THE DAYS	NEARLY EVERY DAY

THOUGHTS THAT YOU WOULD BE BETTER OFF DEAD, OR OF HURTING YOURSELF IN SOME WAY *

NOT AT ALL	SEVERAL DAYS
MORE THAN HALF THE DAYS	NEARLY EVERY DAY

PROSPECTIVE PAIN MANAGEMENT CLIENTS ONLY

HAVE YOU EVER BEEN TREATED BY A PAIN SPECIALIST *

YES

NO

IF YOU HAVE BEEN TREATED BY A PAIN SPECIALIST BEFORE HAVE YOU STOPPED SEEING THE PROVIDER *

YES

NO

WERE YOU RELEASED FROM A PAIN MANAGEMENT GROUP OR SPECIALIST PREVIOUSLY FOR VIOLATION OF POLICY *

YES

NO

RELEASED FROM MORE THAN ONE PAIN MANAGEMENT GROUP/SPECIALIST FOR VIOLATION OF POLICY *

YES

NO

IF YOU WERE PREVIOUSLY MANAGED OR WERE SEEN BY A PAIN MANAGEMENT SPECIALIST PLEASE LIST EACH OF THEM (NAME AND LOCATION/ADDRESS) HERE PAIN SPECIALIST #1 (IF NONE THEN ENTER (NA)) *

PAIN SPECIALIST #2 (IF NONE THEN PLEASE ENTER NA) *

PAIN SPECIALIST #3

PAIN SPECIALIST #4

IF YOU WERE RELEASED BY THE PROVIDER (GROUP) AT ALL TELL US WHY (IF THIS IS NOT APPLICABLE THEN TYPE NA) *

IF YOU VOLUNTARILY LEFT THE PROVIDER (GROUP) TELL US WHY (TYPE NA IF THIS DOES NOT APPLY) *

NAME ALL NARCOTIC MEDICATIONS THAT HAVE BEEN PRESCRIBED FOR YOU FOR CHRONIC PAIN CONTROL *

WHICH STUDIES/TESTS HAVE YOU HAD WITHIN THE LAST 12 MONTHS FOR YOUR COMPLAINT

WHERE WAS THIS RECENT IMAGING AND/OR RECENT TESTING FOR YOUR COMPLAINT DONE. IF NONE DONE TYPE IN NA OR NONE *

LIST ANYTHING/ MEDICATION YOU HAVE TRIED FOR YOUR COMPLAINT THAT
WAS NOT LISTED

Enter your email address here (If you do not have one then please enter NA) *

RE-ENTER YOUR EMAIL ADDRESS

PLEASE ARRIVE 20 MINUTES PRIOR TO YOUR SCHEDULED APPOINTMENT DATE AND TIME. IF KNOWN, PLEASE ENTER YOUR APPOINTMENT DATE AND TIME

WE DO NOT PRESCRIBE OPIOIDS FOR CHRONIC (LONG-TERM) PAIN MANAGEMENT

We recommend that you never discuss your medication or treatment with other persons in the facility except the providers . Also, keep your belongings, including your medications, documents, etc with you or your trusted guardian or representative at all times.

Please sign BELOW here if you are on a computer, or sign with stylus or your finger if you are on a mobile device. PLEASE MAKE SURE YOUR SIGNATURE IS LEGIBLE Thanks, and we look forward to meeting you very soon

*

clear

PLEASE BRING ALL CURRENTLY PRESCRIBED MEDICATIONS TO THIS VISIT INCLUDING RECENT EMPTY BOTTLES

WOMEN IF THERE IS ANY CHANCE THAT YOU ARE CURRENTLY PREGNANT TELL US NOW PLEASE

*

YES, THERE IS A CHANCE THAT I AM CURRENTLY PREGNANT

NO, THERE IS NOT ANY CHANCE THAT I AM CURRENTLY PREGNANT

I AM A MALE AND THIS IS NOT APPLICABLE TO ME

POTENTIAL PAIN MANAGEMENT CLIENTS

For those potentially participating in our pain management programs, please begin keeping some sort of daily journal (diary). And, in this journal please:

1. List daily activities such as exercising house chores, cooking , laying around, yard work, shopping, etc..

2. List the times throughout the day that you actually are taking your medications for pain control

3. List the location of your painful areas as you experience throughout the day

4. Write down pain levels that you experience throughout the day/night 0-10 with the 10 being highest

You can start the journal keeping now or immediately after your first visit with us. This is an expectation that we have of you, unless we say otherwise

Many of our patients use "apps" (applications typically downloaded to a device such as phone or tablet) in order to do this quite nicely. The information can later be sent to our group in a number of ways

The purpose of the journal is to monitor and keep a more accurate daily account of lifestyle and activities as they may certainly affect chronic pain cycles. This is not a "punishment" or just some extra work for you (our healthcare team does review these journals) we are quite serious about them. As well, maintenance of these journals does help to keep some level of client and provider accountability and responsibility to the process of long term management. Over the years this method has really shown that a more thorough and effective approach of and for management is enabled.

The journal information really should be kept nearly daily

START KEEPING THE JOURNAL NOW. Please remember to bring the journal to each visit. It is an important piece and part to your visits with our providers . Please be sure to bring it along with current medication(s) and its bottles- even if the bottles are empty- to each appointment.

Be sure to ask any questions that you may have about the journal, or anything else during your apppointment time or via electronic or other messaging as available.

IF YOU ARE GOING TO NEED A WORK OR SCHOOL NOTE AFTER YOUR VISIT WITH US THIS TIME , PLEASE CHECK THE APPROPRIATE BOX

WORK NOTE

SCHOOL NOTE

WE DO NOT REPLACE LOST OR STOLEN PRESCRIPTIONS OR MEDICATIONS

BE SURE TO GET GREEN CHECK MARK AND COPY YOUR REFERENCE NUMBER DOWN AFTER COMPLETING THE FORM

EPIDURAL	PHYS THERAPY	RADIOFREQUENCY	TENS
BRACING	FACET	TRIGGER POINT	ANTI IMFLAMMATORIES
NARCOTICS	ACUPUNCTURE	MASSAGE	VERTEBROPLASTY
SPINAL CORD STIM	NUCLEOPLASTY	PROLOTHERAPY	JOINT INJ
MEDIAL BRANCH	CHIROPRACTIC	OTHER THERAPY	OTHER MEDS

NAPROXEN	IBUPROFEN	MOTRIN	DICLOFENAC
TYLENOL	CELEBREX	NEURONTIN	GABAPENTIN
LYRICA	CYMBALTA	SAVELLA	BACLOFEN
TIZANIDINE	ZANAFLEX	FLEXERIL	PARFN FRTE
ROBAXIN	METHCARBAMOL	OXYCODONE	HYDROCODONE
LORTAB	SUBOXONE	PERCOCET	SUBUTEX
OXYCONTIN	BUPRENORPHINE	MORPHINE	MS CONTIN
KADIAN	ORAMORPH	OPANA	NUCYNTA
METHADONE	FENTANYL	DURAGESIC	ZIPSOR
FLECTOR	TYLENOL/CODNE	LIDODERM	VOLTAREN
CAPSAICIN	BIOFREEZE	HERBALS	TRAMADOL
ULTRAM ER	EMBEDA	MELOXICAM	MOBIC
NEUROSPEED	EFFEXOR	ELAVIL	PRISTIQ
OTHER	NONE

HEADACHES	BLURRED VISION	WEAKNESS	FATIGUE	DIZZINESS	NUMBNESS
BALANCE	JOINT PAIN	MUSCLE PAIN	SHORTNESS OF BREATH	CHEST PAIN	COUGH
NAUSEA	DIARRHEA	CONSTIPATION	EASY BRUISING	FEVER	NIGHT SWEATS
NONE

X RAY	MRI	DISCOGRAM	MYELOGRAM
ELECTROMYOGRAPHY	NERVE CONDUCTION	BONE SCAN	BONE DENSITY

TF MEDICAL GROUP LLC

Authorization to obtain your healthcare records

WE DO NOT PRESCRIBE OPIOID MEDICATIONS FOR LONG-TERM MANAGEMENT

WE HOPE THAT YOU SHARE OUR ZERO TOLERANCE POLICY FOR ILLEGAL SUBSTANCES

WE DO NOT PRESCRIBE OPIOID MEDICATIONS FOR LONG-TERM MANAGEMENT

SOME THINGS ABOUT YOU

WE HOPE THAT YOU SHARE OUR ZERO TOLERANCE POLICY FOR ILLEGAL SUBSTANCES

WE DO NOT PRESCRIBE OPIOID MEDICATIONS FOR LONG-TERM MANAGEMENT

FIRST COMPLAINT THIS IS YOUR MAIN COMPLAINT

SECOND COMPLAINT

THIRD COMPLAINT

YOUR AND YOUR FAMILY'S MEDICAL AND SURGICAL PAST HISTORY

ALLERGIES

MIND SPIRITUAL WELL BEING

SOCIAL HISTORY

YOUR PREVIOUS TREATMENT FOR YOUR COMPLAINTS

GENERAL SYSTEM REVIEW

Over the last two weeks, how often have you been bothered by any of the following problems- select one choice only

PROSPECTIVE PAIN MANAGEMENT CLIENTS ONLY

WE DO NOT PRESCRIBE OPIOIDS FOR CHRONIC (LONG-TERM) PAIN MANAGEMENT

We recommend that you never discuss your medication or treatment with other persons in the facility except the providers . Also, keep your belongings, including your medications, documents, etc with you or your trusted guardian or representative at all times.

Please sign BELOW here if you are on a computer, or sign with stylus or your finger if you are on a mobile device. PLEASE MAKE SURE YOUR SIGNATURE IS LEGIBLE Thanks, and we look forward to meeting you very soon

PLEASE BRING ALL CURRENTLY PRESCRIBED MEDICATIONS TO THIS VISIT INCLUDING RECENT EMPTY BOTTLES

WOMEN IF THERE IS ANY CHANCE THAT YOU ARE CURRENTLY PREGNANT TELL US NOW PLEASE

POTENTIAL PAIN MANAGEMENT CLIENTS

WE DO NOT REPLACE LOST OR STOLEN PRESCRIPTIONS OR MEDICATIONS

BE SURE TO GET GREEN CHECK MARK AND COPY YOUR REFERENCE NUMBER DOWN AFTER COMPLETING THE FORM

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