PHYSICAL MEDICINE & REHAB CENTER OF ORLANDO

PHYSICAL MEDICINE & REHAB CENTER OF ORLANDO

Pedro T. Oliveros, MD, PT 341 N. Maitland Ave. Ste. 200 Maitland FL 32751 PH: 407-265-2100/FX: 407-265-2872
Name*

First NameLast Name
Date*

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Today's Date
To prevent the spread of COVID-19 and redue the potential risk exposure to our employees and patients please answer the following screening questions:
Have you returned from international travel or been on a cruise within the last 14 days?*

YesNo
Have you had close contact with or cared for someone diagnosed with COVID-19?*

YesNo
Have you (or anyone residing in your home) experienced any cold or flu-like symptoms in the last 14 days (fever , cough, sore throat, difficulty breathing)?*

YesNo
If you answer "yes" to any of the above quetions, please notify the front desk immediately. Thank you!
REASON for your visit:*

Follow Up / RefillsInjectionsNerve TestForms
What is the MAIN ISSUE or concern you wish to discuss today?*
MEDICATIONS that need to be refilled today (please be specific):*
Do you have any side effects from your medications?*

NoYes
If yes, check all that apply

DrowsinessConstipationSkin RashNausea / VomitingOther
Response to treatment: Please check how much RELIEF you have with your current treatment.*

0-10%11-20%21-30%31-40%41=50%51-60%61-70%71-80%81-90%91-100%
Please choose the number that best describes the INTENSITY of pain you are currently in:*

0 (No Pain)12 (Annoying)34 (Nagging, Uncomfortable, Troublesome)56 (Distressing, miserable)78 (Horrible, dreadful, intense)910 (Unbearable, excruciating, worst possible)
Please check the TIMING of your pain*

OccasionalFrequentConstant
How do you DESCRIBE your pain?*

BurningSharpSoreStabbingAchy
Things that make your pain WORSE:*

SittingStandingBendingWalkingLifting
Things that make your pain BETTER:*

TherapyInjectionsRestMedications
Any NEW symptoms since your last visit?*
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PHYSICAL MEDICINE & REHAB CENTER OF ORLANDO

Pedro T. Oliveros, MD, PT Medical Director
AGREEMENT FOR OPIOID MAINTENANCE THERAPY FOR NON CANCER/CANCER PAIN

***Please initial each item***
I agree to use only one physician to prescribe and monitor all opioid medications and adjunctive analgesics (initial)*
I agree to be seen at least once a month and that prescriptions for pain medication(s) will be given only during an office visit or during regular office hours. No refills will be done after hours, on weekends, or during my physical therapy session.*
I agree to keep my pain medication in a safe and secure place. Lost, misplaced or stolen medications may not be replaced result In termination of the doctor/patient relationship.*
I agree not to share or sell my medications to any other person under any circumstances.*
l agree that any evidence of aberrant behavior such as drug hoarding, acquisition of opioid medication from another tampering, uncontrolled dose escalation or reduction, loss of prescriptions or failure to follow the agreement may termination of the doctor/patient relationship.*
I agree to undergo random urine drug screening. If I decide not to provide a urine sample, the doctor may either my opioid medication or terminate the doctor/patient relationship. I understand that I am responsible for for laboratory services that are not covered by my healthcare insurance.*
I agree to allow my physician to contact any healthcare professional, family member(s) pharmacy, legal authority or regulatory agency to provide information about my care or actions if the physician feels It is necessary.*
I agree to a family conference or a conference with a close friend or significant other, if the physician feels it is necessary.*
I agree not to use alcohol or any illicit substances while taking opioid medications.*
I understand the risks associated with opioid medications, which include physical dependence, tolerance, or withdrawal Side effects include rash, constipation, sexual dysfunction, respiratory depression, sedation or the possibility of cognitive (mental status) and/or motor ability.*
I agree to notify the physician if I have a history of alcohol or drug misuse/addiction since he may have to modify my treatment.*
With my initials and signature below, I agree to the above terms so that Dr. Pedro T. Oliveros can provide quality pain management using opioid therapy to decrease my pain and increase my function. A copy of this agreement will be available to me. *
Signature*
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PHYSICAL MEDICINE & REHAB CENTER OF ORLANDO

PHYSICAL MEDICINE & REHAB CENTER OF ORLANDO

AGREEMENT FOR OPIOID MAINTENANCE THERAPY FOR NON CANCER/CANCER PAIN