NAME:_______________________________________________________________________________ ADDRESS:____________________________________________________________________________ HOME TEL. NO.: ___________________________ WORK TEL. NO.:__________________________ MRN: ___________________________________ DOB: ____________________________________ PRIMARY CARE PHYSICIAN: ______________________________________________________________ TEL. NO.: ________________________________ FAX NO.: _______________________________ PAIN DIAGNOSIS & LOCATION: ____________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ PAST PAIN MEDICATION: _________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ PAST PAIN TREATMENTS (including surgery): _________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ PATIENT'S NAME: _______________________________________________________________________ COPIES OF PERTINENT RADIOLOGICAL STUDIES (not done at CPMC): ______________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ PAST PSYCHIATRIC HISTORY AND TREATMENT: ______________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ADDITIONAL INFORMATION: ______________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ REFERRING PHYSICIAN: ___________________________________________________________________ REFERRING PHYSICIAN ADDRESS: __________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ UPIN NO.: ________________________ TEL. NO.: ___________________ FAX NO.: _________________ DATE: __________________________ SIGNATURE OF REFERRING PHYSICIAN: ____________________ PLEASE RETURN THIS COMPLETED FORM WITH RELEVANT MEDICAL RECORDS TO THE ADDRESS AT THE TOP OF THIS FORM.
Please evaluate and treat the following patient for pain management.
(Please print full name)