Jaclyn Hicks

 
 Toufan Razi M.D. 
 Pacific Pain 
 Qualified Medical Evaluator 
 Institute 
 Pain Management Specialist 
 MULTIDICIPLINARY INITIAL EVALUATION REPORT 
 FUNCTIONAL RESTORATION PROGRAM 
 Name: Monica Huffman
 Insurance: Gallagher Bassett 
 Claim#: 002406001366 
 DOB: 1997 Jul 04 
 DOI: 2015 Mar 02
 DOS: 2018 Jul 13
 INTRODUCTION: As part of Mr. Florentino Mejia multidisciplinary initial evaluation for 
 Functional Restoration Program, patient completed a comprehensive medical and psychological 
 evaluation on 2018 Sep 04. In a conference meeting at the Pacific Pain Institute Functional 
 Restoration Program the following providers met to determine patient candidacy for the 
 program: Dr. Toufan Razi and Adriana Flores LPCC. Baseline functional testing and reasonable 
 goals of treatment were established for this patient. 
 A. MEDICAL EVALUATION 
 HISTORY OF PRESENT ILLNESS: Mr. Florentino Mejia is a 28-year-old male who injured his low 
 back during the course of his usual and customary work as a cook. On the date of injury, patient 
 was carrying contained of soap and milk while walking downstairs. He slipped and fell, landing 
 on his buttocks and hitting his back on the steps. He did not lose consciousness, but he did feel 
 immediate pain in his low back. 
 Patient was sent to occupational therapy at North Bay Medical Center where he received initial 
 conservative treatment and completed diagnostic studies. He was placed on modified duty. 
 Patient received oral medications and physical therapy. Mr. Mejia continued his treatment 
 under Dr. Samuel Graves who provided chiropractic sessions. 
 Patient was evaluated by Dr. Vatche Cabayan, orthopedic surgeon on 1/29/2013 who did not 
 recommend surgery. Facer joint and epidural steroid injections were recommended.  
 Pacific Pain Institute Functional Restoration Program. Address: 2410 Merced St San Leondro CA 94577. Phone 
 number (510) xxx xxxx. Fax Number: (510) xxx xxxx. 
 774
