Patient Forms

The intake forms are located below. These are fillable so you can complete the fields and click to select the symptoms and areas. When finished you can print out your completed forms and bring them to your appointment!

Download a blank intake packet here

Have a question or want to schedule a consultation? Get in touch with our team at (580) 771-2011.

The ACellOrtho.com Team

Address:

3414 NW Cache, Suite F

Lawton, OK, 73505

Phone: 580-771-2011

Fax: 877-292-3457

Address:

3414 NW Cache, Suite F

Lawton, OK, 73505

Phone: 580-771-2011

Fax: 877-292-3457

Initial Visit Forms (MEDICAL HISTORY)
Date:

PATIENT NAME (Last, Middle, First):

BIRTH DATE:

SEX:

HEIGHT:

WEIGHT:


REFERRING DOCTOR:
PRIMARY CARE DOCTOR:
RIMARY INSURANCE:
INSURANCE / MEMBER ID:
GROUP NUMBER:
ADDRESS:
CITY:
ZIP CODE:
SOCIAL SECURITY #:
MOBILE PHONE:
(OTHER):

OK TO TEXT APPOINTMENT REMINDERS?

PRIMARY INSURED NAME:
(If different from patient)

RELATIONSHIP:

OTHER:
PRIMARY INSURED SOCIAL SECURITY #:

PAIN QUESTIONNAIRE

WHERE IS YOUR PRIMARY AREA OF PAIN

DOES THE PAIN RADIATE OR GO ANYWHERE?

DOWN THE ARM(S)

DOWN THE LEG(S)

WHEN DID YOUR PAIN START? WHAT YEAR?

STARTED:

TIMING:

HOW LONG HAD PAIN:

WHAT CAUSED YOUR PAIN INITIALLY?

OTHER:
WHERE IS YOUR PRIMARY AREA OF PAIN? (DRAW ON DIAGRAM)
human

PAIN RATING:

BEST

AVERAGE

WORST

DESCRIBE THE PAIN:

WHAT MAKES PAIN WORSE?

WHAT MAKES PAIN WORSE?


Address:

3414 NW Cache, Suite F

Lawton, OK, 73505

Phone: 580-771-2011

Fax: 877-292-3457

Initial Visit Forms (MEDICAL HISTORY)
Date:

PATIENT NAME (Last, Middle, First):

CIRCLE ALL THAT APPLY TO THE PATIENT


HEART/CARDIOVASCULAR

LUNG/PULMONARY

LIVER/KIDNEY

BRAIN/SPINE/NEUROLOGICAL

STOMACH/GASTROINTESTINAL

METABOLIC/ENDOCRINE

BLOOD DISORDER/HEMATOLOGY

JOINT/MUSCULOSKELETAL

PSYCHOLOGICAL/PHYCHIATRIC

MEDICATION ALLERGIES:

DRUG/SUBSTANCE:
REACTION (RASH, ITCHECT):
PHARMACY NAME:
PHONE #:
CITY/STATE:

CURRENT MEDICATION LIST:

PAIN/MEDS:
NAME:MG:Number of Pills per Day:

OTHER PRESCRIBED MEDS:

NAME:FOR?

SOCIAL HISTORY:

EMPLOYMENT:
MARITAL STATUS:

SUBSTANCE USE:

SMOKING:

(# of Years):

ALCOHOL:

COCAINE:

AMPHETAMINE:

SURGICAL HISTORY:

BODY PARTYEARHOSPITALSURGEON

Address:

3414 NW Cache, Suite F

Lawton, OK, 73505

Phone: 580-771-2011

Fax: 877-292-3457

FOLLOW UP VISIT FORM

Date:

PATIENT NAME (Last, Middle, First):

Birth Date:

REVIEW OF SYSTEMS To Be Completed by ALL Patients

(CIRCLE ALL THAT APPLY)

CONSTITUTIONAL SYMPTOMS

HEAD, EYES, EARS, NOSE, THROAT

LUNG/PULMONARY

HEART/CARDIOVASCULAR

STOMACH/GASTROINTESTINAL

JOINT/MUSCULOSKELETAL

PSYCHOLOGICAL/PHYCHIATRIC

SKIN

BRAIN/SPINE/NEUROLOGICAL

METABOLIC/ENDOCRINE


Address:

3414 NW Cache, Suite F

Lawton, OK, 73505

Phone: 580-771-2011

Fax: 877-292-3457

SOAPP-R FORM

The following questions for patients being considered for pain medication.

Please answer each question as honestly as possible there are no right or wrong answers.

NAME:
BIRTH DATE:
DATE:
01234
How often do you have mood swings?
How often have you felt a need for higher doses of medication to treat your pain?
How often have you felt impatient your doctors?
How often have you felt that things are just too overwhelming that you can’t handle them?
How often is there tension in the home?
How often have you counted pain pills to see how many are remaining?
How often have you been concerned that people will judge you for taking pain medication?
How often do you feel bored?
How often have you taken more pain medication than you were supposed to?
How often have you worried about being left alone?
How often have you felt a craving for medication?
How often have others expressed concern over your use of medication?
How often have any of your close friends had a problem with alcohol or drugs?
How often have others told you that you had a bad temper?
How often have you felt consumed by the need to get pain medication?
How often have you run out of pain medication early?
How often have others kept you from getting what you deserve?
How often, in your lifetime, have you had legal problems or been arrested?
How often have you attended an Alcoholics Anonymous or Narcotics Anonymous meeting?
How often have you been in an argument that was so out of control that someone got hurt?
How often have you been sexually abused?
How often have others suggested that you have a drug or alcohol problem?
How often have you had to borrow pain medications from your family or friends?
How often have you been treated for an alcohol or drug problem?

Address:

3414 NW Cache, Suite F

Lawton, OK, 73505

Phone: 580-771-2011

Fax: 877-292-3457

GAD-7

Over the last 2 weeks, how often have you been bothered by the following problems?

(Circle a number to indicate your answer)

Not at AllSeveral DaysMore than Days
Half the Days
Nearly Every
Day
1Feeling nervous, anxious or on edge
2Not being able to stop or control worrying
3Worrying too much about different things
4Trouble relaxing
5Being so restless that it is hard to sit still
6Becoming easily annoyed or irritable
7Feeling afraid as if something awful might happen
For office coding: Total score
TOTAL:

The Patient Health Questionnaire (PHQ-9)

Patient Name:
Date of Visit:

Over the past 2 weeks, how often have you been
bothered by any of the following problems?

Not at AllSeveral DaysMore than Days
Half the Days
Nearly Every
Day
1Little interest or pleasure in doing things
2Feeling down, depressed or hopeless
3Trouble falling asleep, staying asleep, or sleeping too much
4Feeling tired or having little energy
5Poor appetite or overeating
6Feeling bad about yourself - or that you’re a failure or have let yourself or your family down
7Trouble concentrating on things, such as reading the newspaper or watching television
8Moving or speaking so slowly that other people could have noticed. Or, the opposite being so dgety or restless that you have been moving around a lot more than usual
9Thoughts that you would be better off dead or of hurting yourself in some way
For office coding: Total score
TOTAL:
Not difficult at allSomewhat difficultVery difficultExtremely difficult
10If you check off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?

Brian K. Rich, MD

Interventional Pain Management

POLICY STATEMENT

The mission of AIO (aCELLerated Interventional Orthopedics) is to serve patients in their management of pain through a patient centered approach. Our goal is to ensure your healthcare needs are met while your pain level is diminished and quality of life is improved.

As a part of your treatment plan, patients may be asked to:

  1. Please give a 24 hours notice of appointment cancellation. A late-cancellation or no-show fee of $40 will be required before another appointment is made.
  2. We utilize a team-approach in caring for our patients. Patients may have appointments with a Nurse Practitioner or Physician assistant for routine follow up appointments. These providers always consult with & work closely with our Physicians.
  3. AIO requires each patient has a Primary Care Physicians.
  4. Bring your medication ONLY if you are asking for a medication change or if we ask you to bring them.
  5. Your medication may be checked for compliance with a random pill count.
  6. The patient may be asked to count their medication in front of AIO staff. Medication should remain in the patient’s possession AT ALL TIMES
  7. To maintain high levels of care & compliance, AIO providers follow the standard of care guidelines of the following:
    • Oklahoma state department of health
    • Oklahoma Board of Narcotics & Dangerous Drugs
    • Oklahoma Prescription Monitoring Program
    • Oklahoma Anti-drug Diversion Act
    • CDC Guidelines for prescribing opioids for chronic pain
PATIENT SIGNATURE:
DATE:

We want to help you improve your life! Keep in touch with Dr. Rich and get instant access to new blogs, bits from the news, and other resources that can help you control your pain and move forward.