The Helm Center relieves chronic pain and improves quality of life through customized, targeted, contemporary pain management.

INITIAL PAIN MANAGEMENT QUESTIONNAIRE

Welcome to The Helm Center. We are looking forward to providing you with the best care to manage your needs. Please take time to complete the following questionnaire as accurately and completely as possible. We rely on this information to provide you with comprehensive and personalized care. If you have any questions about any of the following sections, please call our front desk at (949) 462-0560.

* indicates a required field
 
First name* :
Middle initial :
Last name* :
 
Marital Status:
Single      Married      Divorced      Widowed
Other     
 
Home Address:
City:
State:
Zip:
 
Home Phone:
Cell Phone:
Work Telephone:
Fax Number:
 
Employer/School:
Occupation:
 
Email Address:
 
Date of birth:
 
Race:
American Indian Alaskan Native Asian / Pacific Islander
Black White Hispanic
I refuse to answer this question
 
Primary Language: English Spanish
  Other:
 
Social Security Number*:
Driver's License No.:
Driver's License State:
 
Living Will?    
Spouse or Parent Name:
Emergency Contact Other Than Spouse:
Emergency Contact Telephone:
 
Gender: Male: Female:
Preferred Pharmacy:
Name
Address
Phone
 
How did you hear about us?
 
Type of Insurance:

 
 
 
 
 
Name of Financially Responsible Person (if Different from Patient):
Address (if Different from Patient):
Home Telephone:
Work Telephone:
 
Primary Health Insurance Co. Name:
Policy Holder:
Policy Holder Date of Birth:
Policy Holder's Relationship to Patient:      
 
Social Security Number:
Insurance Co. Phone Number:
Insurance Co. Address:
ID/Policy No*:
(Please enter NA if this information is not applicable)
Group No*:
(Please enter NA if this information is not applicable)
 
Secondary Health Insurance Co. Name:
Policy Holder:
Policy Holder Date of Birth:
Policy Holder's Relationship to Patient:      
 
Social Security Number:
Insurance Co. Phone Number:
Insurance Co. Address:
ID/Policy No:
Group No:
 
Primary Care Physician (first and last name):
Primary Care Physician Phone Number:
 
Referring Physician (first and last name):
Address:
Telephone:
 
Please tell us in one sentence, why are you here? (e.g. Low back pain)
Please describe the location and type of pain:
About how long ago did your pain start?
How did your pain begin? (Accident, Fall, Gradually, Suddenly, etc.)
How frequent is your pain?
Constant

Intermittent (comes and goes)
 
Which Words Would you use to describe your pain?
Throbbing Aching Sharp Shooting Dull
Tingling Burning Pins & Needles Hot Cold
Gnawing Squeezing Spasming / Cramping Tender(Sensitive to touch)
 
Which activities are you not able to perform due to your pain?
Which activities make your pain worse?(e.g. Sitting, standing, walking, etc.)
 
What activities make your pain better?
 
How do you rate the intensity of your pain? (0 = no pain & 10 = worst pain imaginable)
1     2     3     4     5     6     7     8     9     10
                                   
 
Can you walk/stand for 30 minutes? Yes No
 
How does your pain affect your sleeping?
I sleep well.
I have difficulty falling asleep.
I have difficulty maintaining my sleep.
 
What type of doctors have you seen for the above condition? (e.g. Chiropractor, Orthopedic surgeon, etc)
 
Work Related?    
Accident Case?    
Automobile Involved?    
Have You Missed Time From Work?    
If Yes Please Specify Dates:

If Due to Work-Related Injury, Fill out the Section Below.

Date of Injury:
Was Injury Reported to Supervisor?    
Name of Supervisor:
Employer at Time of Injury:
Address:
Telephone:
Description of Injury:
Workers’ Compensation Insurance Carrier:
Workers’ Compensation Insurance Carrier Address:
Claim Number:
Adjuster Name:
Telephone:
Fax:
Is An Attorney Assisting You With This Worker's Comp Claim?    
Attorney's Name:
Telephone:
 
 
Have you had imaging/diagnostic studies for this condition? (e.g. X-ray, MRI, CT scan, nerve Conduction Study, EMG, etc.)
If so, please provide the following information:
Type of test/study: Date: Facility name and phone number where test was performed:
 
What have you done so far for your pain?
Surgery      Helped  Did not change
Physical Therapy      Helped  Did not change
Acupuncture      Helped  Did not change
Chiropractic Treatment      Helped  Did not change
Biofeedback Therapy      Helped  Did not change
Massage      Helped  Did not change
Trigger Point Injections      Helped  Did not change
Epidural Injections      Helped  Did not change
Other injections       Helped   Did not change
Other treatments      Helped      Did not change
 
When I Stand or walk I experience:
Weakness      Numbness      Tingling      Pain
 
I can stand for minutes before I need to rest.
I can walk for minutes before I need to rest.
 
My discomfort/pain is relieved when I sit or bend forward: Yes No
Please indicate the type of treatment
Do you have allergies to any medication?
Yes No
If yes, please list medication and the type of reaction:
Medication: Reaction:
 
What medications have you tried in the past for your pain?
Medication:
Helped Did not help
Medication:
Helped Did not help
Medication:
Helped Did not help
 
What medications do you currently take?
Medication: Dose: Dose(s)/Day: Prescribing Physician:
 
Please let us know if you take any of the following "Blood Thinners":
Aspirin
Coumadin / Warfarin
Plavix
Aggrenox
Lovenox
Paradaxa
Other:
 
Please list all surgeries you have had in the past:
Surgery Date (Month/Year)
 
Do you have any serious illness or medical conditions that we should know about? If so, please list: (e.g. Diabetes, Hypertension, Hepatitis, etc)
 
Social History
Children:
Do you have any children? Yes No
If so, what year/years were they born?
 
Drug use history:
Have you ever had any problem with addiction or substance abuse? Yes No
If yes, please explain:
 
Education:
What is your highest level of education?
 
Employment:
Do you work? Yes No
If yes, what do you do?
How many hours per week?
If no, when was the last time you worked?
What did you do?
 
Pregnancy:
Are you or can you be pregnant:      Yes      No
 
Tobacco Use:
Do you currently smoke? Yes No
Do you smoke Marijuana? Yes No
If yes, do you have a medical marijuana license? Yes No
License expiration date:
*If applicable, please provide a copy of your medical marijuana license to us.
 
Review of system:
Have you experienced any of the following symptoms during the last 7 days?
 
Constitutional:
Fever
Chills
Night sweats
Weakness
Fatigue
Unexplained weight loss
 
Head/Ears/Eyes/Nose/Throat:
Visual change or difficulty with vision
Snoring
Hoarseness
Difficulty with swallowing
Nose bleeds
Difficulty with hearing or ringing in the ears
 
Cardiovascular:
History of chest pain or heart attack
Shortness of breath
Swelling in the ankles or feet
Shortness of breath on exertion
 
Respiratory:
Wheezing
Cough
Blood in sputum
 
Gastrointestinal:
Nausea
History of Jaundice
Vomiting
Constipation
Diarrhea
Black or tarry stools
 
Genitourinary problems:
Frequency
Difficulty Urinating
Incontinence
Kidney Stones
 
Musculoskeletal:
Back pain
Neck pain
Joint swelling
Joint pain / Stiffness
Muscle spasm
Difficulty walking
 
Skin:
Rash
Mole changes
Skin ulcerations
 
Neurological:
Seisure
Stroke
Numbness
Tingling
Syncope
 
Hematological/Lymphatic:
Node swelling
Easy bruising
Bleeding disorder
 
Psychiatric:
Depression
Suicidal thoughts
Anxiety
Stressed
 
Endocrine:
Diabetes
Thyroid disorder
Adrenal Insufficency
 

NOTICE: PATIENT PRIVACY

 
We are committed to preserving the privacy of your personal health information. In fact, we are required by law to protect the privacy of your medication information and to provide you with Notice describing:
 
HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED,
 
DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION
 
We may require your written consent before we use or disclose to others your medical information for purposes of providing or arranging for your healthcare, the payment for or reimbursement of the care that we provide to you, and the related administrative activities supporting your treatment. We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization.
 
As our patient, you have important rights relating to inspecting and copying your medical information that we maintain, amending or correcting that information, obtaining an accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.
 
We have available a detailed Notice of Privacy which fully explains your rights and our obligations under the law. We may revise our Notice from time to time. The effective date at the top left hand side of this page indicates the date of the most current Notice in effect. You have the right to receive a copy of our most current Notice in effect. If you have not yet reserved a copy of our current Notice, please ask at the front desk and we provide you with a copy.
 
If you have any questions, concerns or complaints about the Notice or your medical information, please contact Dr. Helm at (949) 462-0560.
 
Signature
 
Date
 
PLEASE LIST THOSE INDIVIDUALS WITH THEIR RELATIONSHIP TO YOU WITH WHOM WE MAY COMMUNICATE.
 
Name/Relationship
 
Name/Relationship
 
 

Treatment Plan Using Prescription Opioids

 
Please fill out the Treatment Plan Using Prescription Opioids Form if you think we may be providing you controlled substances, such as opioids. This form is suggested by the Medical Board of California.
 
The purpose of this agreement is to structure our plan to work together to treat your chronic pain. This will protect your access to controlled substances and our ability to prescribe them to you.
 
I (patient) understand the following.
 
Opioids have been prescribed to me on a trial basis. One of the goals of this treatment is to improve my ability to perform various functions, including return to work. If significant demonstrable improvement in my functional capabilities does not result from this trial of treatment, my prescriber may determine to end the trial.
Goal for improved function:
 
Opioids are being prescribed to make my pain tolerable but may not cause it to disappear entirely. If that goal is not reached, my physician may end the trial.
Goal for reduction of pain:
 
Drowsiness and slowed reflexes can be a temporary side effect of opioids, especially during dosage adjustments. If I am experiencing drowsiness while taking opioids, I agree not to drive a vehicle nor perform other tasks that could involve danger to myself or others.
 
Using opioids to treat chronic pain will result in the development of a physical dependence on this medication, and sudden decreases or discontinuation of the medication will lead to symptoms of opioid withdrawal. These symptoms can include: runny nose, yawning, large pupils, goose bumps, abdominal pain and cramping, diarrhea, vomiting, irritability, aches and flu-like symptoms. I understand that opioid withdrawal is uncomfortable but not physically life threatening.
 
There is a small risk that opioid addiction can occur. Almost always, this occurs in patients with a personal or family history of other drug or alcohol abuse. If it appears that I may be developing addiction, my physician may determine to end the trial.
 
I agree to the following:
I agree not to take more medication than prescribed and not to take doses more frequently than prescribed.
 
I agree to keep the prescribed medication in a safe and secure place, and that lost, damaged, or stolen medication will not be replaced.
 
I agree not to share, sell, or in any way provide my medication to any other person.
 
I agree to obtain prescription medication from one designated licensed pharmacist. I understand that my doctor may check the Utah Controlled Substance Database at any time to check my compliance.
 
I agree not to seek or obtain ANY mood-modifying medication, including pain relievers or tranquilizers from ANY other prescriber without first discussing this with my prescriber. If a situation arises in which I have no alternative but to obtain my necessary prescription from another prescriber, I will advise that prescriber of this agreement. I will then immediately advise my prescriber that I obtained a prescription from another prescriber.
 
I agree to refrain from the use of ALL other mood-modifying drugs, including alcohol, unless agreed to by my prescriber. The moderate use of nicotine and caffeine are an exception to this restriction.
 
I agree to submit to random urine, blood or saliva testing, at my prescriber's request, to verify compliance with this, and to be seen by an addiction specialist if requested.
 
I agree to attend and participate fully in any other assessments of pain treatment programs which may be recommended by the prescriber at any time.
 
I understand that ANY deviation from the above agreement may be grounds for the prescriber to stop prescribing opioid therapy at any time.
 
If this form accurately represents your doctor's discussion with you, and if you are satisfied with the explanation given, you must type your full name here to indicate your consent to use the controlled substances in treating your intractable pain prior to commencing the treatment.
 
Date
 
 

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

 
Authorization for Use/Disclosure of Information: I voluntarily authorize and direct the health care provider named below to disclose my health information during the term of this Authorization to the recipient that I have identified below
 
Name of Provider: The Helm Center for Pain Management
Address of Provider: 24902 Moulton Parkway, Ste. 200
Laguna Woods, CA 92637
Phone: (949) 462-0560
Fax: (949) 462-3910
 
Recipient and Address for Delivery of Records
 
Phone
 
Fax
 
Purpose I understand that the specific purpose of this Authorization is:
 
Questions: I may contact my health care provider for answers to my questions about the privacy of my health information at my health care provider's regular office telephone number. I understand that I have a right to receive a copy of this authorization from my health care provider.
 
Information to be disclosed: This authorization permits the above named health care provider to disclose the following medical records:
 
All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me, including without limitation, x-rays, HIV/AIDS status, genetic testing, psychotherapy notes and other mental health information, drug, alcohol or other controlled substance information, billing information, correspondence, and records from other health care providers that the above-named health care provider may hold.
 
All of my health information described above except for the following:
 
Only the following records or types of health information: (Insert dates of treatment, types of treatment or other designation.)
 
Term: This authorization will remain in effect for one year from the date this authorization is signed.
 
Redisclosure: I understand that once my health care provider discloses my health information to the recipient identified above, my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
 
Refusal to sign/right to revoke: I understand that I may refuse to sign or may revoke (at any time) this Authorization for any reason and that such refusal or revocation will not affect the commencement, continuation or quality of my treatment by my health care provider.
 
Revocation: I understand that the Authorization will remain in effect until the term of this Authorization expires or I provide a written notice of revocation to my health care provider at my health care provider's regular office address. The revocation will be effective immediately upon my health care provider's receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before the provider received my written notice of revocation.
 
Photocopy: A photocopy, fax or electronic copy of this authorization shall be considered as effective and as valid as the original.
 
Date:
 
Please type full name if you authorize this disclosure:
 
 

Patient Pain Medication Agreement and Consent

 
Please fill out the Patient Pain Medication Agreement and Consent Form if you think we may be providing you controlled substances, such as opioids. This form is suggested by the Medical Board of California.
 
This agreement is important for you:
• You will have a safe and controlled pain treatment plan.
• Your medicines have a high potential for abuse. They can be dangerous if used in the wrong way. You need to understand the risks that come from use of pain medicines.
 
Please read and make sure you understand each statement here. Here are rules about refills and health risks. Here are also reasons for stopping your pain control treatment.
 
I Will:
 
  • I will only get my pain medicine from this clinic during scheduled appointments.
  • I will take my pain medicine the way that my healthcare provider has ordered.
  • I will be honest with all my healthcare providers if I am using street drugs.
  • I will be honest about all the medicine I use. This includes medicine from stores and herbal medicines.
  • I will be honest about my full health history.
  • I will tell my healthcare provider if I go to an emergency room for any reasons.
  • If I get pain medicine from an emergency room, I will tell my healthcare provider.
  • I will call this office if I am prescribed any new medicine.
  • I will call this office if I have a reaction to any medicine.
  • I will tell all other healthcare providers that I have a pain medication agreement.
  • I will tell the emergency room people that I have a pain medication agreement.
  • I will take drug tests and other tests when I am told to do so.
  • I will go to office visits when I am told to do so.
  • I will go to physical therapy when I am told to do so.
  • I will go to counseling when I am told to do so.
  • I will follow directions for all treatment.
  • I will show up on time for all appointments.
  • I will make an appointment for refills before I run out of medicine.
  • I will tell my health provider if I will be out of town so that I can get my refills.
  • I will get past health records from other offi ces when needed.
  • I will deliver these records by hand if needed. I will do this within one month of being asked. I will pay for these records if needed.
  • I will give permission to this clinic to talk about my treatment with pharmacies, doctors, nurses, and others who are helping me.
  • I will give permission to any healthcare provider to get information from this clinic about my health and my pain treatment.
  • I will take responsibility if I overdose myself accidentally or on purpose.
  • I will tell my healthcare provider if I plan to become pregnant.
  • I will tell my healthcare provider if I am pregnant while I am taking pain medicine.
  • I will only take this medicine the way I was told to take it.
 
I Will Not:
 
  • I will not share or sell, or trade any of my medicine.
  • I will not drink alcohol or take street drugs while I am taking pain medicine.
  • I know that I cannot call the office to have my medicine refi lled over the phone.
  • I will not go to the emergency room or other doctors for more pain medicine or other drugs.
  • I know that when I drive a car, I must be fully alert. I know that when I use machines, I must also be fully alert. Pain medicines can make me less alert. When I am taking pain medicines, I need to be sure that I am alert. I need to be sure that it is safe for me to drive a car or use a machine
  • I will not stand in high places or do anything to hurt others aft er I have taken pain medicine.
  • I will not leave my medicine where it can be stolen or where others can take it.
  • I will not leave my medicine where children can find it.
  • I will not suddenly stop taking my medicine. I know that if I do this, I can have withdrawals.
 
When Using a Pharmacy, I Will:
 
  • I will use the same pharmacy for all my medicines.
  • I will not ask for early refi lls or more pain medicine, even if I lose my medicine.
 
I Know That:
 
  • Pain management may include other treatment. Some treatment may not include medicine.
  • Pain medicine will probably not get rid of all of my pain. Pain medicine can reduce my pain so that I can do more and have a better life.
  • Part of my treatment is to reduce my need for pain medicine.
  • If the pain medicines work, I will continue to use them. If the pain medicine does not help me, it will be stopped.
  • My medicines will not be replaced if any of these things happen: Medicine is lost. Medicine gets wet. Medicine is destroyed.
  • If my medicine is stolen, I might be able to get more medicine if I get a report from the police about the medicine being stolen.
  • Any of my healthcare providers can find out from the California Prescription Drug Monitoring Program about any other medicines I get from any other pharmacy in California. This is called a CURES report.
  • My healthcare provider may contact the drug enforcement agency, if I try to get other doctors to give me pain medicine.
  • Healthcare providers may contact the drug enforcement agency if I am not honest about how I take pain medicine.
  • My doctor and my clinic will help with any investigation if I am suspected of prescription drug abuse.
  • I may be sent somewhere else for drug abuse or addiction help if I need it.
  • Pain medicine can be addictive. This means that my body may need more and more pain medicine or that it can be hard for me to stop taking this medicine.
  • If I suddenly stop using the medicine, I can get withdrawals.
  • If I use too much pain medicine, I can end up with health problems. I could die.
  • If I mix medicines, I could also end up with health problems. I could die.
  • Here are some things that could go wrong if I use too much medicine or mix medicines:
Overdose Addiction Constipation Vomiting Sleepiness
Slower Reflexes Nausea Difficulty With Urination Confusion Itching
Problems With Sex Dry Mouth Depression Trouble Breathing Death
 
CAUSE FOR DISMISSAL FROM THIS CLINIC:
 
  • I know that the pain medicines may be stopped if I break any part of this contract.
 
Comments:
 
Filling out the fields below means that I have read this contract. I am filling this out to say that I understand all of this contract.
 
This Agreement is entered into on:
 
Please type full name if you agree to the terms of this agreement:
 
 

ASSIGNMENT & RELEASE

 

I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO THE HELM CENTER FOR PAIN MANAGEMENT. I AM FINANCIALLY RESPONSIBLE FOR NON-COVERED SERVICES.

 

“Under California law, I am required to inform you that I have (or a member of my family has) a financial interest in California Specialty Surgery Center to which I may refer you for services. There may be other organizations from which you can obtain these services. I will discuss alternatives with you”

 
* Please type full name if the above information is correct and you agree to the assignment and release:
 
Date:
 

* Enter the Text to the Left: