Mr. Jerry Terry DVM

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 Recv'd Date: 20140909 Bill DCN: 2014252GJ000800 
 Toufan Razi M.D. 
 Pacific Pain 
 Qualified Medical Evaluator 
 Institute 
 Pain Management Specialist 
 PACIFIC PAIN INSTITUTE FUNCTIONAL RESTORATION PROGRAM 
 PROGRESS REPORT WEEK # 4 
 Name: Craig Dominguez
 Insurance: Gallagher Bassett 
 Claim#: 002406001366 
 DOB: 22 February 1985 
 DOI: 08 March 2015
 INTRODUCTION: 
 As part of his comprehensive treatment plan for patient's Chronic Pain Syndrome, patient has 
 successfully completed the FOURTH WEEK on the Pacific Pain Institute Functional Restoration 
 Program.
 According to MTUS guidelines, It Is not suggested that a continuous course of treatment be 
 Interrupted at two weeks solely to document these gains, If there are preliminary Indications 
 that these gains are being made on a concurrent basis. Patient has currently completed his 80 
 authorized hours of Functional Restoration Program, plus 48 additional hours. 
 The following constitutes the Integrative summary report generated by Dr. Toufan Razi and 
 LPCC Adriana Flores after the patient has completed the fourth week of the program on 
 8/15/2014.
 A. MEDICAL EVALUATION 
 SYMPTOMS PROGRESSION: The patient is a 29-year-old male. He has lower back pain, lumbar 
 radiculopathy and chronic pain syndrome. Patient has participated In the Pacific Pain Institute 
 Functional Restoration Program for the last 4 weeks. The patient has remained very 
 cooperative despite having low back pain and burning sensation running down his right leg. 
 The patient has remained compliant and has participated in all the exercises activities that have 
 been prescribed for him. 
 Pacific Pain Institute Functional Restoration Program. Address: 2439 Merced St San Legndro CA 94539. Phone 
 number. (510) 94249 Fax number: (510) Random_5_digit_number 
 1139
