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  • SERVICES
    • Physicians Services
    • Neurology
    • Pain Psychology
    • COVID-19 Recovery Program
    • Concussion Care Clinic
    • Platelet Rich Plasma Therapy
    • Chiropractic
    • Healing Arts Center
    • Physical Therapy
    • Medical Fitness
    • Independent Medical Exams
    • Internal Medicine
    • Physicians Services
    • Neurology
    • Pain Psychology
    • COVID-19 Recovery Program
    • Concussion Care Clinic
    • PRP And Bone Marrow Aspirate
    • Chiropractic
    • Healing Arts Center
    • Physical Therapy
    • Medical Fitness
    • Independent Medical Exams
    • Internal Medicine
  • OUR TEAM
    • Physicians
    • Physical Therapy Staff
    • Physician Assistants | Nurse Practitioners
    • Psychology Staff
    • Medical Fitness
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Physical Medicine & Rehab / Pain Management Eval Packets

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  3. Physical Medicine & Rehab / Pain Management Eval Packets
Physical Medicine & Rehab / Pain Management Eval PacketsKurt Effertz2023-07-27T16:08:26-04:00

Pain Management

Patient Information

Date of Birth(Required)
Address(Required)

Primary Insurance Information

Name of Policy Holder
Date of Birth
Address

Secondary Insurance Information

Name of Policy Holder
Date of Birth
Address

Work / Auto Related Injury

Date of Injury/Accident:
Contact Name
Address
Employer Address
Contact Name
Adjuster Handling Claim Name
Attorney Handling Claim Name

Patient Pain History

Date of Injury
Date of Accident
Accident Details
Select all that apply
Which of the following tests have been done for your condition?
X-ray date
MRI date
Cat scan date
Bone scan date
EMG date
Other date
Please bring any/all X-rays, MRIs, and Medical Records that may pertain to your current problem/injury.
Treatment
Body Part
When (Month/Year)
Facility
How Long
 
Please check any treatments that have been helpful.

Past Medical History

Do you or have you had any problems with the following? (Check all that apply)
Please list surgeries you have had
Surgery Type
Date
 
Family History

Employment Status

Date last worked
Shifts
Hours worked per day
Days worked per shift
Shift

Activities of Daily Living

Please list up to four things in your life that you can't do or have difficulty with because of your pain and which most dearly you want restored? These should be simple, realistic daily life improvements that other people can see most of the time.
At one time how long can you:
Sit
Stand
Walk
Do you use any of the following

Review of systems

Do you have problems with any of the following? Please check all that apply.
General
Skin
Head
Eyes/Ears/Nose/Throat
Neck
Cardiac
Respiratory
Circulation
Gastrointestinal
Genitourinary
Musculoskeletal
Nervous System
Metabolism/Endocrine
Hematology
Psychiatric
Women Only
Date of last menstrual period

To ensure we are providing quality care, we need information from you and need to provide you with information about our practice policies. Below are links to our practice policies. Please click on each one to review prior to your visit. When you arrive for your appointment, you will be asked to electronically sign that you have reviewed and understand them.

Forms to be completed:
  • Medication intake form
  • SOAPP form
Policies to view only
  • NERA Policies
  • HIPAA Policy
  • Medication Agreement
  • Medication Refill Policy
  • Beneficiary Info Notice/ACO
  • KeyHIE
  • PA PDMP
  • Establishing Care/Team Approach

Also, please complete the below “New Patient Packet” prior to arriving for your appointment. This information is important for your physician to review with you during your initial visit and if not completed, it may delay your appointment time. You do not need to print. Once you complete and click submit, our office will securely receive your responses.

Many of our patients experience acute and chronic pain. Northeast Rehab Physicians will work with you to create an effective treatment plan, tailored just for you. The goals of a treatment plan often include reducing pain, maximizing your ability to perform functions of daily living, and helping improve your quality of life. Patient Health Questionnaires are tools used to assist in creating your treatment plan. At the end of this packet, you will be asked to also complete the SOAPP-14 questionnaire. You may be asked to update this information annually or more often as your treatment plan changes over time.

To provide you with secure electronic access to our physicians and staff, Northeast Rehab utilizes a Patient Portal. You need an access code to register. Once you receive your access code, you can click here to register. Through our patient portal, you can request appointments, update your medical history, medications, and allergies, and send a note to your provider. We encourage you to sign up for the Patient Portal before your first visit.

Hassle Free Appointments

570.344.3788

Existing patients please call the office where you are currently being treated.

* New Patients Only

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