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BRIEF ENCOUNTER FORM
DEMOGRAPHICS
Patient Name
*
First Name
Last Name
Date of Birth: (ex: Month, Day, Year: January, 01, 1990)
MM
DD
YYYY
DOS Date of Service)
*
MM
DD
YYYY
Payor / Insurance Type
Referring Doctor(s) [PLEASE NOTE A PROVIDER WITH AN NPI IS REQUIRED]:
*
First Name
Last Name
CC/HPI/PE
Chief Complaint / Injured Sites / Covered Body Parts
*
Brief HPI
Physical Exam Templates (Abnormals):
HEADACHES
CERVICAL FACET - LEFT
CERVICAL FACET - RIGHT
CERVICAL RADICULOPATHY
THORACIC FACET - LEFT
THORACIC FACET - RIGHT
THORACIC RADICULOPATHY
LUMBAR FACET - LEFT
LUMBAR FACET - RIGHT
LUMBAR RADICULOPATHY
LUMBAR SPINAL STENOSIS
LOW BACK PAIN (ASK MD FOR DETAILS)
SACROILIAC JOINT - LEFT
SACROILIAC JOINT - RIGHT
TAILBONE
CRPS/RSD UE (UPPER EXTREMITY) - LEFT
CRPS/RSD UE (UPER EXTREMITY) - RIGHT
CRPS/RSD LE (LOWER EXTREMITY) - LEFT
CRPS/RSD LE (LOWER EXTREMITY) - RIGHT
HIP PAIN - LEFT
HIP PAIN - RIGHT
SHOULDER PAIN - LEFT
SHOULDER PAIN - RIGHT
KNEE PAIN - LEFT
KNEE PAIN - RIGHT
MUSCLE PAIN (OFFICE ONLY)
VEINS (ASK MD FOR DETAILS)
ELBOW - LEFT
ELBOW - RIGHT
WRIST / HAND - LEFT
WRIST / HAND - RIGHT
ANKLE/FOOT - LEFT
ANKLE/FOOT - RIGHT
MALAISE / FATIGUE (ASK MD WHAT LABS ARE NEEDED)
BOTOX FOR MIGRAINES
BOTOX FOR CERVICAL DYSTONIA
BOTOX OF AXILLARY HYPERHYDROSIS
PROCEDURES/DIAGNOSTIC TESTS
In-Office Procedure(s) / Diagnostic Test(s) Performed
Ultrasound / X-Ray Test(s) Performed
Please Scribe Using Templates for Diagnostic Ultrasound Reports
LEFT
RIGHT
NORMAL
MILD
MODERATE
SEVERE
Shoulder(s)
Elbow(s)
Wrist(s)
Hand(s)
Hip(s)
Knee(s)
Ankle(s)
Foot/Feet
Spine - Cervical
Spine - Thoracic
Spine - Lumbar
MEDICATIONS
PHARMACY NAME / NUMBER / ADDRESS
COMMON MEDICATIONS
Gabapentin 600 mg 1 tab PO TID #90
Flexeril (Cyclobenzaprine) 10 mg 1 tab PO BID #60
Naproxen 500 mg 1 tab PO BID PRN #60
Tramadol 50 mg PO TID #90
Percocet 5/325 mg 1 tab PO TID # 90
Medrol Dospak
BOTOX FOR MIGRAINOUS HEADACHES - SENT TO WALGREENS SPECIALTY PHARMACY in Hawthorne, NY
Other Medications
PSYCH Referrals
Psychology - Therapy
Psychology - SCS EVALUATION
Psychology - PNS EVALUATION
WELLNESS Referrals
PT (Physical Therapy)
OT (Occupational Therapy)
Acupuncture
Chiropractic
EMG/NCS
EMG UE #1 (UPPER EXTREMITY)
EMG UE #2 - At Least 6 Months + 1 Day After Previous EMG UE
EMG LE #1 (LOWER EXTREMITY)
EMG LE #2 - At Least 6 Months + 1 Day After Previous EMG LE
BALANCE TESTING
TCD #1 (Transcranial Doppler)
TCD #2 (Transcranial Doppler) - At Least 12 Months + 1 Day After
VNG #1 (VIDEONYSTAGMOGRAPHY)
VNG #2 (VIDEONYSTAGMOGRAPHY) - At Least 12 Months + 1 Day After Previous EMG LE
VEIN STUDIES
ABI #1 (Ankle-Brachial Index)
ABI #2 (Ankle-Brachial Index) - At Least 12 Months +1 Day After Previous ABI
ARTERIAL US (Lower Extremity Arterial Ultrasound)
Arterial US #2 (Lower Extremity Arterial Ultrasound) - At Least 12 Months +1 Day After Previous Arterial US
VEIN US (Lower Extremity Venous Ultrasound)
Venous US #2 (Lower Extremity Venous Ultrasound) - At Least 12 Months +1 Day After Previous Venous US
SURGERY PROTOCOL
HEADACHE
CERVICAL RADICULOPATHY
CERVICAL FACET - LEFT
CERVICAL FACET - RIGHT
CRPS (COMPLEX REGIONAL PAIN SYNDROME) - UE - LEFT
CRPS (COMPLEX REGIONAL PAIN SYNDROME) - UE - RIGHT
LUMBAR RADICULOPATHY
SACROILIAC JOINT - LEFT
SACROILIAC JOINT - RIGHT
LUMBAR FACET - LEFT
LUMBAR FACET - RIGHT
CRPS (COMPLEX REGIONAL PAIN SYNDROME) - LE - LEFT
CRPS (COMPLEX REGIONAL PAIN SYNDROME) - LE - RIGHT
SHOULDER - LEFT
SHOULDER - RIGHT
ELBOW - LEFT
ELBOW - RIGHT
WRIST - LEFT
WRIST - RIGHT
HIP - LEFT
HIP - RIGHT
KNEE - LEFT
KNEE - RIGHT
ANKLE - LEFT
ANKLE - RIGHT
Surgery - OTHER
Minimally Invasive Spine
VIA DISC
Percutaneous Discectomy (No Fault ONLY)
Endoscopic Discectomy (All Insurances)
MINUTE MAN
SI (Sacroliiac Joiint) Fusion
Facet Fusion
SCS - CERVICAL
SCS - LUMBAR
PNS - SHOULDER
PNS - WRIST
PNS - HIP
PNS - KNEE
PNS - ANKLE / FOOT
Minimally Invasive Spine - OTHER
Regenerative / Aesthetics / Weight Loss
PRP
STEM CELL
OZEMPIC
BOTOX
FILLERS
REGENERATIVE / AESTHETICS - AREA or BODY PART
SPECIAL COMMENTS / INSTRUCTIONS:
ELECTRONIC SIGNATURE SECTION:
PHYSICIAN NAME / E-SIGNATURE:
*
KARAN JOHAR, MD (PAIN MANAGEMENT)
JOHN PITMAN, MD (PLASTIC SURGERY)
JUAN-CARLOS BARRERA-MARTINEZ, MD (NEUROLOGY)
ROY BERENHOLTZ, MD (ANESTHESIOLOGY)
ARON ROVNER, MD (ORTHOPAEDIC SURGERY)
RUSSELL SILVER, MD (PHYSICAL MEDICINE & REHABILITATION)
PHYSICIAN ASSISTANT - TEDDY O. UZAMERE, PA-C
Thank you!
