use this diagram to indicate the location and type of...

Center for Wellness and Pain Care of 8 New Patient Intake Form – Revised May 4, 2017

NEW PATIENT CLINICAL INFORMATION

Your Name: _____________________________________________

Email Address: _____________________________________________

Height: _______ Weight: _______ DOB: ________ Today’s Date: ________

Where is your worst area of pain located, please list one area? ______________________________________________

What is the main reason for today’s visit? ________________________________________________________________

Does the pain radiate? if yes, where? ___________________________________________________________________

Please list additional areas of pain ______________________________________________________________________

Approximately when did this pain begin? ________________________________________________________________

What caused your current pain episode? _________________________________________________________________

How did your current pain episode begin? ❑ Gradually ❑ Suddenly

Since your pain began, how has it changed? ❑ Decreased ❑ Increased ❑ Stayed the same

USE THIS DIAGRAM TO INDICATE THE LOCATION AND TYPE OF YOUR PAIN

Mark the Drawing with the Following Letters That Best

Describe Your Symptoms:

❑ Aching ❑ Numbness ❑ Spasming ❑ Throbbing ❑ Stabbing/Sharp

❑ Cramping ❑ Shock-Like ❑ Squeezing ❑ Hot/Burning ❑ Dull

❑ Tiring/Exhausting ❑ Shooting ❑ Tingling/Pins & Needles

What word best describes the frequency of your pain? ❑ Constant ❑ Intermittent

When is the pain at its worst? ❑ Mornings ❑ During the day ❑ Evenings ❑ Middle of the night

“N” = numbness

“S” = stabbing “B” = burning “P” = pins and needles “A” = aching

Onset Of Symptoms

Pain Description – Check All Of The Following That Describe Your Pain

Pain Frequency


❑ Balance Problem ❑ Bladder Incontinence ❑ Bowel Incontinence ❑ Chills

❑ Difficulty Walking ❑ Fevers ❑ Nausea ❑ Vomiting

❑ Numbness or Tingling? Please list where _____________________________________________________________

❑ Weakness? Please list where _______________________________________________________________________

❑ I HAVE NOT RECENTLY DEVELOPED ANY OF THE ABOVE CONDITIONS

MARK ALL OF THE FOLLOWING TESTS YOU HAVE HAD THAT ARE RELATED TO YOUR CURRENT PAIN COMPLAINTS

❑ MRI of the _________________________________ Date: ____________ Facility: _____________________________

❑ X-ray of the ________________________________ Date: ____________ Facility: _____________________________

❑ CT scan of the ______________________________ Date: ____________ Facility: _____________________________

❑ EMG/NCV study of the _______________________ Date: ____________ Facility: _____________________________

❑ Ultrasound of the ___________________________ Date: ____________ Facility: _____________________________

❑ Other diagnostic testing ___________________________________________________________________________

❑ I HAVE NOT HAD ANY DIAGNOSTIC TESTS PERFORMED FOR MY CURRENT PAIN COMPLAINTS

MARK ANY OF THE FOLLOWING PAIN TREATMENTS YOU HAVE UNDERGONE PRIOR TO TODAY’S VISIT

❑ Chiropractic ❑ Physical Therapy ❑ Spine Surgery ❑ Trigger Point Injections If Yes where __________________

❑ Epidural Steroid Injection: check all levels that apply ❑ Cervical ❑ Thoracic ❑ Lumbar

❑ Medial Branch Blocks or Facet Injections: check all levels that apply ❑ Cervical ❑ Thoracic ❑ Lumbar

❑ Radiofrequency Ablation: check all levels that apply ❑ Cervical ❑ Thoracic ❑ Lumbar

❑ Spinal Column Stimulator: check one ❑ Trial Only ❑ Permanent Implant

❑ Other Treatments: ________________________________________________________________________________

❑ I HAVE NOT HAD ANY PRIOR TREATMENTS FOR MY CURRENT PAIN COMPLAINTS

In The Past Three Months Have You Developed Any New:

Diagnostic Tests And Imaging

Pain Treatment History


Are you taking a prescribed blood-thinner medication? ❑ Yes ❑ No

If yes, please check which one:

❑ Aggrenox ❑ Coumadin ❑ Effient ❑ Eliquis ❑ Lovenox ❑ Plavix ❑ Pletal ❑ Pradaxa

❑ Ticlid ❑ Warfarin ❑ Xarelto ❑ Other _____________________________________________________

Who prescribes your blood thinner medication? List Doctor’s name and phone number: _____________________________

Please list ALL medications you are currently taking. Attach an additional sheet, if required.

Medication Name Dose Frequency Medication Name Dose Frequency

1. 7.

2. 8.

3. 9.

4. 10.

5. 11.

6. 12.

Please indicate any surgical procedures you have had done in the past, including the date, type, and any pertinent details.

❑ I HAVE NEVER HAD ANY SURGICAL PROCEDURES DONE

Abdominal Surgery:

❑ Gallbladder Removal _______________________

❑ Appendectomy ___________________________

Female Surgeries:

❑ Caesarean Section _________________________

❑ Hysterectomy ____________________________

❑ Laparoscopy _____________________________

❑ Ovarian _________________________________

Heart Surgery:

❑ Valve Replacement ________________________

❑ Aneurysm Repair __________________________

❑ Stent Placement __________________________

Joint Surgery:

❑ Shoulder ________________________________

❑ Hip ____________________________________

❑ Knee ___________________________________

Spine / Back Surgery:

❑ Discectomy (levels) ________________________________

❑ Laminectomy _____________________________________

❑ Spinal Fusion (levels) _______________________________

Other Common Surgeries:

❑ Hemorrhoid Surgery _______________________________

❑ Hernia Repair _____________________________________

❑ Thyroidectomy ___________________________________

❑ Tonsillectomy ____________________________________

❑ Vascular Surgery __________________________________

PLEASE LIST ANY OTHER SURGERIES AND DATES (attach an additional sheet if necessary):

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

Current Medications

Past Surgical History


Are you allergic to: ❑ Iodine or ❑ Tape

Are you allergic to latex? ❑ Yes ❑ No

If yes: Do you require special medications or rescue measures to manage your latex allergy ❑ Yes ❑ No

Are you allergic to shellfish? ❑ Yes ❑ No Are you allergic to peanuts? ❑ Yes ❑ No

❑ I HAVE NO SIGNIFICANT FAMILY MEDICAL HISTORY

❑ I AM ADOPTED (No Medical History Available)

Mark all appropriate diagnoses as they pertain to your biological MOTHER AND FATHER only

Madre

Padre

Other medical problems: _____________________________________________________________________________

Do you have any allergies or reactions to medications? ❑ Yes ❑ No

If yes, please list all medications you are allergic to and the reaction you have:

Medication Name Allergic Reaction Type

1.

2.

3.

4.

5.

6.

Environmental Allergies

Latex Allergy

Food Allergies

Family History

Drug Allergies


MARK THE FOLLOWING CONDITIONS/DISEASES THAT YOU HAVE BEEN TREATED FOR IN THE PAST:

General Medical ❑ Cancer Type _________________

❑ Diabetes Type ______________

❑ HIV / AIDS

Gastrointestinal ❑ Bowel Incontinence

❑ Acid Reflux (GERD)

❑ Gastrointestinal Bleeding

❑ Constipation

Head/Eyes/Ears/Nose/Throat ❑ Glaucoma

❑ Headaches

❑ Head Injury

❑ Hyperthyroidism

❑ Hypothyroidism

❑ Migraines

Cardiovascular / Hematologic ❑ Anemia/Bleeding Disorders

❑ Heart Attack

❑ High Blood Pressure

❑ Hypertension

❑ High Cholesterol

❑ Mitral Valve Prolapse

❑ Murmur

❑ Pacemaker/Defibrillator

❑ Poor Circulation

❑ Stroke

Respiratory

❑ Asthma

❑ Bronchitis

❑ Emphysema / COPD

❑ Pneumonia

❑ Tuberculosis

❑ Valley Fever

Musculoskeletal ❑ Amputation

❑ Bursitis

❑ Carpal Tunnel Syndrome

❑ Fibromyalgia

❑ Joint Injury

❑ Osteoarthritis

❑ Osteoporosis

❑ Phantom Limb Pain

❑ Rheumatoid arthritis

❑ Vertebral Compression

Genitourinary/Nephrology ❑ Bladder Infection(s)

❑ Dialysis

❑ Kidney Infection(s)

❑ Kidney Stones

❑ Urinary Incontinence

Hepatic

❑ Hepatitis A – circle one

(active / inactive / unsure)

❑ Hepatitis B – circle one


❑ Hepatitis C – circle one


Neuropsychological ❑ Alzheimer Disease

❑ Bipolar Disorder

❑ Depression

❑ Epilepsy

❑ Multiple Sclerosis

❑ Paralysis

❑ Peripheral Neuropathy

❑ Schizophrenia

❑ CRPS/Reflex Sympathetic Dystrophy

❑ Other Diagnosed Conditions:

________________________________

________________________________

________________________________

________________________________

Have you received a pneumonia vaccination? ❑ Yes ❑ No If yes, when? __________________________________

Do you exercise? ❑ Yes ❑ No If yes, how many days per week? ___________________________________________

What type of exercise do you perform? ❑ Bicycle ❑ Cardio ❑ Strength ❑ Swimming ❑ Walking

Other: _______________________ How much time do you exercise on the days that you do exercise? ______________

Have you had two or more falls in the past year? ❑ Yes ❑ No

Post Medical History / Problem List

Immunization History

Activity


Are you capable of becoming pregnant? ❑ Yes ❑ No If yes, are you currently pregnant? ❑ Yes ❑ No

Highest level of education obtained: ❑ Grammar School ❑ High School ❑ College ❑ Post-Graduate

Alcohol Use:

❑ Current Alcoholism ❑ Daily Limited Alcohol Use

❑ History of Alcoholism ❑ Never Drinks Alcohol

❑ Social Alcohol Use

Tobacco Use:

❑ Current Tobacco User

❑ Former Tobacco User

❑ Never Used Tobacco

Drug Use:

❑ Denies Any Illegal Drug Use ❑ Currently Using Illegal Drugs, list: ______________________________________

❑ Currently Using Someone Else’s Prescription Medications, list ____________________________________________

❑ Formerly Used Illegal Drugs (not currently using); list ___________________________________________________

Have you ever abused narcotic or prescription medications? ❑ No ❑ Yes Which ones: _____________________

Are you working? ❑ Yes ❑ No ❑ Student ❑ Retired Are you on disability? ❑ Yes ❑ No

FOR EACH QUESTION, PLEASE INDICATE YOUR RESPONSE BY CIRCLING A NUMBER FROM 0 TO 10. (Please answer all questions)

YOUR PAIN: 0 = No Pain 10 = Extreme Pain

My current pain is .............................................................................................0 1 2 3 4 5 6 7 8 9 10

During the past week, the best my pain has been is.........................................0 1 2 3 4 5 6 7 8 9 10

During the past week, the worst my pain has been is ......

...................

.............0 1 2 3 4 5 6 7 8 9 10

During the past week, my average pain has been.............................................0 1 2 3 4 5 6 7 8 9 10

During the past 3 months, my average pain has been......................................0 1 2 3 4 5 6 7 8 9 10

YOUR FEELINGS: (During the past week I have felt) 0 = Strongly Disagree 10 = Strongly Agree

Afraid..................................................................................................................0 1 2 3 4 5 6 7 8 9 10

Depressed ..........................................................................................................0 1 2 3 4 5 6 7 8 9 10

Tired ...................................................................................................................0 1 2 3 4 5 6 7 8 9 10

Anxious ..............................................................................................................0 1 2 3 4 5 6 7 8 9 10

Stressed..............................................................................................................0 1 2 3 4 5 6 7 8 9 10

YOUR CLINICAL OUTCOMES: (During the past week) 0 = Strongly Disagree 10 = Strongly Agree

I had trouble sleeping ....................................................................................... 0 1 2 3 4 5 6 7 8 9 10

I had trouble feeling comfortable …………………………….………………….………………. 0 1 2 3 4 5 6 7 8 9 10

I was less independent ......................................................................................0 1 2 3 4 5 6 7 8 9 10

I was unable to work (or perform normal tasks) ……….………………………….…...... 0 1 2 3 4 5 6 7 8 9 10

I needed to take more medication.……………………………………………...…..…...……. 0 1 2 3 4 5 6 7 8 9 10

YOUR ACTIVITIES: (During the past week I was NOT able to) 0 = Strongly Disagree 10 = Strongly Agree

Go to the store .................................................................................................. 0 1 2 3 4 5 6 7 8 9 10

Do chores in my home....................................................................................... 0 1 2 3 4 5 6 7 8 9 10

Enjoy my friends and family .............................................................................. 0 1 2 3 4 5 6 7 8 9 10

Exercise (include walking) ................................................................................. 0 1 2 3 4 5 6 7 8 9 10

Participate in my favorite hobbies……………………………………………….………....….....0 1 2 3 4 5 6 7 8 9 10

Social History

Pain Level


Mark the following symptoms that you currently suffer from.

Note: Diagnosed conditions/diseases should be noted under Past Medical History, above

Constitutional:

❑ Chills

❑ Difficulty Sleeping

❑ Easy Bruising

❑ Excessive Sweating

❑ Excessive Thirst

❑ Fatigue

❑ Fevers

❑ Low Sex Drive

❑ Night Sweats

❑ Unexplained Weight Gain

❑ Unexplained Weight Loss

❑ Weakness

Eyes:

❑ Recent Visual Changes

Ears/Nose/Throat/Neck:

❑ Difficulty Hearing

❑ Earaches

❑ Hay fever/Allergies

❑ Nosebleeds

❑ Recurrent Sore Throats

❑ Ringing in the Ears

❑ Sinus Problems

Cardiovascular/Respiratory:

❑ Chest Pain

❑ Cough

❑ Fainting

❑ Irregular Heartbeat

❑ Lightheadedness

❑ Shortness of Breath During exertion

❑ Swelling in the Feet

❑ Wheezing

❑ High Blood Pressure

Gastrointestinal:

❑ Abdominal Cramps

❑ Acid Reflux

❑ Constipation

❑ Coffee Ground Appearance in Vomit

❑ Dark and Tarry Stools

❑ Diarrhea

❑ Hernia

❑ Vomiting

Musculoskeletal:

❑ Back Pain

❑ Joint Pain

❑ Joint Swelling

❑ Muscle Spasms

❑ Neck Pain

Neurological:

❑ Dizziness

❑ Headaches

❑ Fainting

❑ Instability When Walking

❑ Numbness/Tingling

❑ Seizures

Psychiatric: ❑ Anxiety/Stress

❑ Depressed Mood

❑ Suicidal Thoughts

❑ Suicidal Planning

Review Of Systems


I certify that the above information is accurate, complete and true.

I authorize CWPC and any associates, assistants, and other health care providers it may deem necessary, to treat my condition. I understand that no warranty or guarantee has been made of a specific result or cure. I agree to actively participate in my care to maximize its effectiveness. I give my consent for CWPC to retrieve and review my medication history. I understand that this will become part of my medical record.

I acknowledge that I have had the opportunity to review CWPCs Notice of Privacy Practices, which is displayed for public inspection at its facility and on its website. This Notice describes how my protected health information may be used and disclosed, and how I may access my health records.

I authorize the CWPC to release my Protected Health Information (medical records) in accordance with its Notice of Privacy Practices. This includes, but is not limited to, release to my referring physician, primary care physician, and any physician(s) I may be referred to. I also authorize CWPC to release any information required in obtaining procedure authorization or the processing of any insurance claims.

I understand that CWPC will not release my Protected Health Information to any other party (including family) without my completing a written “Patient Authorization for Use and Disclosure of Protected Health Information” form, available at its facility and on its website.

In the event that I am asked to provide a urine and/or blood sample, I voluntarily seek laboratory services and hereby consent to provide a urine and/or blood sample as requested. I have the right to refuse specific tests, but understand this may impact my pain management treatment. This agreement can be revoked by me at any time with written notification and is valid until revoked. I hereby assign to the Laboratory my right to the insurance benefits that may be payable to me for services provided, arising from any policy of insurance, self-insured health plan, Medicare or Medicaid in my name or in my behalf. I further authorize payment of benefits directly to the Laboratory. I understand that acceptance of insurance assignment does not relieve me from any responsibility concerning payment for laboratory services and that I am financially responsible for all charges whether or not they are covered by my insurance. I also acknowledge that the Laboratory may be an out-of-network provider with my insurer. Payment in full is expected 30 days of being notified of any balance due. Please note that in the event that you fail to make payment when due, this account will be referred to a collection agency for collections. In that event, the contingency fee assessed by the collection agency will be added to the principal and interest due. You will be additionally liable for attorney fees. Both collection agency fees and attorney fees will increase the balance you owe.

Signed: __________________________________________________________ Date: _______________________

Print Name: ___________________________________________________

Date of Birth: _______________________

Medical History And Consent For Treatment

CENTER FOR WELLNESS AND PAIN CARE PATIENT CARE ASSESSMENT

The Center for Wellness Patient Care Assessment is a patient management questionnaire developed to guide

and track level of care decisions for CWPCLV patients in need of health services. This assessment is also intended to support improved outcomes and help assess medical necessity for any services that may be provided.

PLEASE COMPLETE THE SURVEY BELOW SO THAT WE MAY DETERMINE SOME OF THE SYMPTOMS YOU ARE EXPERIENCING

Patient Name: _______________________________ Date of Birth: _________ Telephone: _________________ Gender: ❑ Female ❑ Male

Are you taking any other medication outside what Center of Wellness prescribes to you? Please list any other current prescriptions, over the counter

medications and any dietary supplements you currently take or have taken within the last 60 days.

___________________________________________________________________________________________________________________________

Please list any hormone related medications or therapies (contraceptives, IUDs, bio-identical hormones, etc.) you have taken within the last 60 days.

___________________________________________________________________________________________________________________________

EVERYONE (please check answer Yes / No to the following questions) CARDIOVASCULAR HORMONE

❑ YES ❑ NO Have you ever had a heart attack or other heart condition? ❑ YES ❑ NO Do you have trouble falling/staying asleep?

❑ YES ❑ NO Have you had any type heart procedures or surgery? ❑ YES ❑ NO Do you feel fatigued throughout the day?

❑ YES ❑ NO Are you currently taking any heart medication? ❑ YES ❑ NO Have you experienced weight gain this past year?

❑ YES ❑ NO Are you currently taking any blood thinner medication? ❑ YES ❑ NO Do you feel a loss of libido or change in sexual desire?

❑ YES ❑ NO Are you currently taking any statin cholesterol medications? ❑ YES ❑ NO Do you feel sad, irritable, suffer from mood swings?

MENTAL HEALTH ❑ YES ❑ NO Do you have difficulty putting on muscle?

❑ YES ❑ NO Have you ever been treated for depression or bipolar disorder? ❑ YES ❑ NO Have you noticed a decline in normal strength?

❑ YES ❑ NO Are you on any type of depression or mood altering medications? ❑ YES ❑ NO Trouble concentrating or remembering things?

Example: Prozac – Well Buterin – Xanax – Paxcel – Cymbalta ❑ YES ❑ NO Do you suffer from acne or have oily skin?

❑ YES ❑ NO Do you feel depressed or ever have suicidal thoughts? ❑ YES ❑ NO Do you have reduced interest in normal activities?

BRACES FOR BACK AND KNEE BRACES ❑ YES ❑ NO Do you feel a decrease in self-confidence or motivation?

❑ YES ❑ NO Are you experiencing any back or neck pain? DIABETES

❑ YES ❑ NO Has this office ever offered you a back or knee braces? ❑ YES ❑ NO Do you have diabetes, hypertension or hyperlipidemia?

EVERYONE ( please check all that apply )

HORMONE and MENTAL HEALTH ❑ Hungry or not, I snack on foods at home or at work, and if there’s food around me, I’ll probably eat it.

❑ I rarely take the time to plan my meals, so most are take-out or eaten in restaurants.

❑ I have difficulty controlling my portion sizes.

❑ I want to exercise but have little time to devote to being more active because of my hectic schedule .

❑ Being physically active has never been one of my priorities.

❑ Negative self-talk makes me my own worst enemy and I feel ashamed of my body.

❑ Food and drink is my trusted friend and comfort source and I find myself eating and drinking instead of expressing my emotions.

❑ I’m doubtful that I will ever find someone who can help me lose weight.

EVERYONE ( please check any symptoms or conditions that you currently have or previously had in the past )

MENTAL HEALTH CARDIOVASCULAR HORMONE

❑ Bipolar Disorder ❑ Depression ❑ Heart Attack ❑ High Blood Pressure ❑ Loss of Mental Clarity ❑ Fatigue

❑ Anxiety / Stress ❑ Schizophrenia ❑ High Cholesterol ❑ Irregular Heartbeat ❑ Difficulty Sleeping ❑ Low Sex Drive

❑ Suicidal Thoughts ❑ Seizures ❑ Pacemaker/Defibrillator ❑ Murmur ❑ Weight Gain ❑ Weakness

Page 1 of 2 Assessment for Medical Necessity – revised 6-1-17

WOMEN ( please check symptoms )

HORMONE and MENTAL HEALTH ❑ Hot Flashes / Night Sweats

❑ Painful Menstrual Cramps

❑ Mood Swings

❑ Irregular Periods

❑ PMS symptoms

❑ Weight Gain

❑ Thinning Hair

❑ Vaginal Dryness

❑ Irritability

❑ Loss of Libido

❑ Insomnia

❑ Breast Swelling

❑ Stiff Achy Joints

❑ Headaches

❑ Gas, Diarrhea, Constipation

Patient Signature: ____________________________________________

Patient Name: ______________________________ Date: ___________

I have correctly answered all of the questions to the best of my ability. I have not

been offered any compensation or inducement to complete this questionnaire.

Please check the boxes below if you have had any of the tests performed at this practice in the past.

( If YES please include date of test )

❑ Blood Test

❑ PGX Test

❑ Skin Biopsy

Test Date: _______________

Test Date: _______________

Test Date: _______________

TESTS ORDERED BY PHYSICIAN

❑ Blood Test ❑ PGX Test ❑ Skin Biopsy

Today's Date Ordered: _______________________

of 2 Assessment for Medical Necessity – revised 5-15-17

USED BY OFFICE STAFF ONLY MENTAL HEALTH and PAIN MANAGEMENT – PGX Testing CARDIOVASCULAR – PGX Testing XXX F31.30 Bipolar disorder, current episode depressed, mild or

moderate severity, unspecified XX XXX I20.0 Unstable angina

F31.31 Bipolar disorder, current episode depressed, mild I20.1 Angina pectoris with documented spasm

F31.32 Bipolar disorder, current episode depressed, moderate

I20.8 Other forms of angina pectoris

F31.4 Bipolar disorder, current episode depressed, severe, without psychotic features

I20.9 Angina pectoris, unspecified

F31.5 Bipolar disorder, current episode depressed, severe, with psychotic features

I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

F31.60 Bipolar disorder, current episode mixed, unspecified

I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery

F31.61 Bipolar disorder, current episode mixed, mild

I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery

F31.62 Bipolar disorder, current episode mixed, moderate I21.29 ST elevation (STEMI) myocardial infarction involving other sites

F31.63 Bipolar disorder, current episode mixed, severe, without psychotic features

I21.3 ST elevation (STEMI) myocardial infarction of unspecified site

F31.64 Bipolar disorder, current episode mixed, severe, with psychotic features

I21.4 Non-ST elevation (NSTEMI) myocardial infarction

F31.75 Bipolar disorder, in partial remission, most recent

episode depressed

I24.0 Acute coronary thrombosis not resulting in myocardial infarction

F31.76 Bipolar disorder, in full remission, most recent episode depressed

I24.1 Dressler’s syndrome

F31.77 Bipolar disorder, in partial remission, most recent episode mixed

I24.8 Other forms of acute ischemic heart disease

F31.78 Bipolar disorder, in full remission, most recent episode mixed

I24.9 Acute ischemic heart disease, unspecified

F31.9 Bipolar disorder, unspecified

I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris

F32.9 Major depressive disorder, single episode, unspecified

I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with unstable angina pectoris

F33.0 Major depressive disorder, recurrent, mild

I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris

F33.1 Major depressive disorder, recurrent, moderate

I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s) with unstable angina pectoris

F33.2 Major depressive disorder, recurrent severe without psychotic features

I25.730 Atherosclerosis of nonautologous biological coronary artery bypass graft(s) unstable angina pectoris

F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms

I25.750 Atherosclerosis of native coronary artery of transplanted heart with unstable angina

F33.40 Major depressive disorder, recurrent, in remission, unspecified

I25.760 Atherosclerosis of bypass graft of coronary artery of transplanted heart with unstable angina

F33.41 Major depressive disorder, recurrent, in partial remission

I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable angina pectoris

F33.42 Major depressive disorder, recurrent, in remission I51.9 Heart disease, unspecified

F33.9 Major depressive disorder, recurrent, unspecified G10 Huntington’s Disease

HORMONE DEFECIENCY – Blood Test HORMONE DEFECIENCY – Blood Test D51.3 Other dietary vitamin B12 deficiency anemia F39 Unspecified Mood D/O

D53.9 Nutritional anemia, unspecified F52.21 Male Erectile D/O

D64.9 Anemia, unspecified or anything related to anemia G47.0 Insomnia

E03.9 Hypothyroidism, unspecified M81.0 Age-related osteoporosis without current pathological fracture

E07.9 D/O of Thyroid N50.0 Trophy of testis

E10.9 Type 1 diabetes mellitus without complications N52.9 Male Erectile dysfunction, unspecified

E11.9 Type 2 diabetes mellitus without complications N92.6 Irregular Menstruation

E23.0 Hypopituitarism N95.9 Unspecified menopausal/premenopausal disorder

E23.6 Other disorders of pituitary gland Elevated R35.0 Frequency of micturition

E27.49 Other adrenocortical insufficiency R35.1 Nycturia

E28.0 Estrogen excess R53.1 Weakness

E29.1 Testicular Hypofunction R53.83 Other Fatigue

E53.8 Deficiency of B vitamins R68.82 Decreased Libido

E55.9 Vitamin D deficiency, unspecified Z12.5 Encounter for screening for malignant neoplasm of prostate

E63.9 Nutritional deficiency, unspecified Z51.81 Encounter for therapeutic drug level monitoring

E66.9 Obesity, Unspecified Z79.890 HRT (postmenopausal)

E78.0 Pure hypercholesterolemia Z79.891 Long term (current) use of opiate analgesic

E78.5 Hyperlipidemia, unspecified Z79.899 Other long term current drug therapy

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