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ADVANCED PAIN CONSULTANTS

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ADVANCED PAIN CONSULTANTS
KRAFT CENTER FOR PAIN CONTROL, LLC
Raimundo F. Leon, M.D.
Date:
Dear:
We would like to confirm your appointment with Dr. Leon or Dr. Prater. Enclosed is the information
packet, as you can see it is very extensive. Please complete this questionnaire and packet as fully as
possible, as this will greatly assist the Doctor in your diagnosis and/or treatment. If you have any
questions regarding any of the items in the enclosed packet, we will happily answer them for you in
person on the day scheduled below.
Kindly bring the following items to your appointment to avoid delays or having to reschedule your
appointment.
1. This entire packet (completed)
2. Your insurance card (s)
3
. You
r current Driver’s License (photo Identification)
4
.
MRI, CT and X-Ray reports
Your appointment date is scheduled for:
DATE: TIME:
For your convenience, we have included a map of our different locations. We look forward to seeing
you and thank you in advanced for your cooperation.
Office in Henderson
1701 Green Valley Parkway
Building 2, Suite B
Henderson, NV 89074
Main Office (West)
2650 Crimson Canyon Drive
Las Vegas, NV 89128
Flamingo Office (East)
2121 E. Flamingo Road
Suite 212
Las Vegas, NV 89119
Telephone: 702-731-2642
Fax: 702-791-2070
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ADVANCED PAIN CONSULTANTS
KRAFT CENTER FOR PAIN CONTROL, LLC
2650 Crimson Canyon Drive
Las Vegas NV 89128
(Office) 702-731-2642 - (Fax) 702-791-2070
Raimundo F. Leon, M.D.
Disclosure of Worker’s Compensation Claims
The purpose of this form is to determine whether or not the condition for which the physician will treat you is in any way
related to a claim that could be considered under Worker’s Compensation Laws. By providing us with this information, we
can properly coordinate the billing of your account. If this does not apply to you, please mark “NO” and sign at the bottom
of the page.
1. Is the condition for which you are seeing the physician today related to an injury that occurred while on the job?
Yes No
2. Have you EVER filed a Worker’s Compensation claim?
Yes No
3. If you answered Yes above, what body part(s) were related?
What were your injuries? What body part(s) were related?
4. What is the current status of your Worker’s Compensation claim?
Open Case Closed Case Trying to re-open
PATIENT’S SIGNATURE: DATE:
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MEDICAL INFORMATION
PATIENT NAME: DATE:
Please list all health care providers, including (Emergency Room Visits, Physical Therapists, Chiropractors, Physicians, Etc.,)
that you have seen for this problem:
1. 2.
3. 4.
Have you ever had any of the following?
Yes No Yes No
⃝ ⃝ Allergies (Medications) ⃝ ⃝ High Blood Pressure
⃝ ⃝ Excessive Thirst or Urination
⃝ ⃝ Diabetes (High Blood Sugar) ⃝ ⃝ Neurologic Condition
⃝ ⃝ Stomach Ulcers ⃝ ⃝ Stroke
⃝ ⃝
Bleeding (Gums, Rectal, Nose, ) ⃝ ⃝ Seizures
⃝ ⃝ Heart Condition/Chest Pain
Have you ever sought medical treatment for neck, mid-back, low-back or extremity pain?
Yes No
Have you ever had a work related injury?
Yes No
Have you ever been involved in a motor vehicle accident?
Yes No
Please list all medications you are currently taking and the reason for
taking them:
Medication Medical Condition
Surgical History
Type of Surgery Date
Low Back (Lumbar)
Neck (Cervical)
Mid-Back (Thoracic)
Other Surgeries:
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PAIN QUESTIONNAIRE
PATIENT NAME: DATE:
Using the diagram, draw the areas which are
affected by your pain.
Pain scale: Please rate your pain
1 2 3 4 5 6 7 8 9 10
Describe your pain:
Burning Aching Throbbing Constant
Intermittent
Dull
Electric Shock
Unpredictable
Sharp
Stays in one place
Moves Around
Shoots someplace
Front
Back
Right
Right
Left
When did your pain begin? (Date)
Was there an accident? Yes No
(Date)
Describe what happened:
¿Do you have an attorney? Yes No Attorney’s Name:
Of the following, which have you tried to help alleviate your current pain?
Medication Chiropractor Physical Therapy TENS Unit Hypnosis
BioFeedback Surgery Nerve Blocks Psychology Pain Treatments
Which of the following above have helped you the most and how?
List all medications and/or dyes you are ALLERGIC to:
Height: (feet) (inches)
Weight: (lb) Your Age:
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ADVANCED PAIN CONSULTANTS
Patient Demographic
Name: Date of Birth: Age:
Sex: F M
Address: City: State: Zip Code:
Home Phone: Cell Phone: Work Phone:
Employer: Social Security Number:
Occupation:
Emergency Contact:
Name: Telephone: Relationship:
What body part is related to this claim?
Place an (X) in the space provided to indicate the coverage for this injury (Check only One)
1. Workmen’s Comp 2. Health Insurance 5. Cash
3. Attorney Lien 4. Auto Med-Pay
Next complete the appropriate numbered section that corresponds to your selection above.
1. Workmen’s Comp
Company Name: Telephone:
Contact: Claim #: Date of Injury:
2. Health Insurance
Primary Company: Secondary Company:
Address: Address:
City: State: Zip Code: City: State: Zip Code:
Insured: DOB: Insured: DOB:
Insured SSN: Insured SSN:
Employer: Employer:
Policy #: Policy #:
Group #: Group #:
3. Attorney Lien 4. Auto Med-Pay
Attorney Name:
Law Firm:
Telephone: Contact:
Date of Injury:
Address:
City: State: Zip Code:
In
surance Company:
Telephone: Contact:
Date of Injury:
Name of Insured:
Claim/Policy #:
Were YOU the: DRIVER PASSENGER OTHER
PATIENT SIGNATURE: DATE:
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ADVANCED PAIN CONSULTANTS
REVIEW OF SYMPTOMS
Yes
No
Constitutional
Have you had recent weight gain or loss?
Do you have regular fevers or chills?
Do you have night time sweats?
Neurologic
Have you ever had a stroke?
Do you have frequent headaches?
Have you ever passed out?
Have you experienced changes in your vision, hearing, smell or taste?
Pulmonary
Do you have chronic cough?
Have you ever coughed up blood?
Do you awaken at night short of breath?
Cardiovascular
Have you ever had a heart attack?
Do you have chest pain?
Do you have heart failure?
Do you have heart valve problems?
Genitourinary
Have you ever had blood in your urine?
Do you have frequent urinary tract infections?
Do you have a history of kidney disease?
Gastrointestinal
Do you have a history of ulcers?
Do you have nausea and vomiting currently?
Have you ever vomited blood?
Have you had liver problems?
Muscolusketal
Do you have swelling, redness or pain in your joints
Do you have skin rashes?
Do your muscles cramp easily?
Psychiatric
Have you had a psychiatric illness?
Do you have a history of depression?
Have you been treated by a psychiatrist/psychologist?
Hematologic
Have you had a history of anemia?
Do you bleed / bruise easily?
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Completed 26 January 2022

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