Online Form Patient Center New Patient Information Please fill out the following questionnaire prior to your first appointment. Thank you! Step 1 of 6 16% Your InformationName* First Last Patient Address* Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Can we leave a message?* Yes No Alternate PhoneEmail Birth date* Month Day Year Emergency Contact InformationEmergency contact name* First Last Relationship to patient Emergency phone*Can we leave a message? Yes No Alternate emergency phoneInsurance informationName of Subscriber First Last Relationship to patientSelect one...SelfSpouseChildParentOtherSubscriber's date of birth Month Day Year Subscriber's employer Insurance Company Insurance ID# Group #(on card) Secondary Insurance informationName of Subscriber First Last Relationship to patientSelect one...SelfSpouseChildParentOtherSubscriber's date of birth Month Day Year Subscriber's employer Insurance Company Insurance ID# Group #(on card) Other Insurance informationType of InsuranceSelect one...Workman's CompensationAuto InsuranceClaim # Claim adjuster name Claim adjuster phone Claim adjuster fax Referring PhysicianReferring physician name* First Last Referring physician address Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Referring physician phonePrimary PhysicianPrimary physician name First Last Primary physician address Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary physician phone Indicate location of pain (check all that apply) Abdomen Arm Left Arm Right Buttock Left Buttock Right Chest Elbow Left Elbow Right Foot Left Foot Right Groin Left Groin Right Hand Left Hand Right Head Hip Left Hip Right Knee Left Knee Right Leg Left Lower Leg Right Lower Lower Back Mid Back Neck Shoulder Left Shoulder Right Thigh Left Thigh Right Upper Back Other pain location (please describe) History of Present IllnessUnder what circumstances did your pain begin? accident at work accident at home work related pain just began motor vehicle accident following surgery following illness other Please describe other circumstances Place of employment Date of injury MM slash DD slash YYYY Type of work What were you doing when the pain occurredCurrently, what is your pain score?Select one...012345678910What is the highest your pain score that you have ever had?Select one...012345678910What is the lowest pain score that you have ever had?Select one...012345678910How long have you had this pain problem (yrs/months/days) When did you first notice your pain? Timing of your pain (when is it the worst) First thing in the morning Later in the morning Afternoon Evening Bedtime Pain is ALWAYS the same Description of your pain Burning Sharp Aching Throbbing Shooting Stabbing Other Please describe your pain Associated signs and symptoms Numbness Tingling Pins and Needles Weakness Coldness Swelling Muscle Spasm Tightness Skin Discoloration Bowel or Bladder Problems What activities increase your pain Sitting Standing Lying Worry/Stress Driving Walking Weather Time of Day Activities Sex Which of the following decrease your pain Rest Lying Medications Sitting Standing Drug/Alcohol Physical Activity Time of Day Please indicate which of the following you have tried if anyAcupuncture* Yes No How long, was it helpful?* Date of last treatment / use* Biofeedback* Yes No How long, was it helpful?* Date of last treatment / use* Chiropractor* Yes No How long, was it helpful?* Date of last treatment / use* Heat* Yes No How long, was it helpful* Date of last treatment / use* Hypnosis* Yes No How long, was it helpful* Date of last treatment / use* Ice* Yes No How long, was it helpful* Date of last treatment / use* Illicit (street drugs)* Yes No How long, was it helpful* Date of last treatment / use* Massage* Yes No How long, was it helpful* Date of last treatment / use* Prescribed pain medicine* Yes No How long, was it helpful* Date of last treatment / use* Physical therapy* Yes No Where did you go How long, was it helpful* Date of last treatment / use* Nerve blocks* Yes No How long, was it helpful* Date and location of injections* Therapy/counseling* Yes No How long, was it helpful* Date of last treatment / use* Surgery* Yes No How long, was it helpful* Date of surgeries* Steroid treatment* Yes No How long, was it helpful* Date and location of last treatment* TENS* Yes No How long, was it helpful* Date of last treatment / use* Procedure/injection* Yes No How long, was it helpful Date and location of all procedures/injections* Do you currently use or have you ever used Walker Cane Wheelchair Medical HistoryHave you had* Anemia Angina/Chest Pain Anxiety Aspirin/Anti- Inflammatory Use Asthma/Emphysema/Bronchitis Atrial Fibrillation Bladder Incontinence Bleeding/Bruising/Clotting Disorder Blood Thinner Use Bone/Muscle Pain Bowel Incontinence Cancer Chest Pain Congestive Heart Failure Constipation Depression Diabetes (Insulin Dependent) Diabetes (Non-Insulin Dependent) Ear/Nose/Throat Problems Eye/Vision Problems Fainting/Black Outs Fevers/Chills Gerd/Acid Reflux Heart Attack Heart Murmur/Rheumatic Fever Hepatitis Herpes/Other Hiatal Hernia HIV Hypertension (High Blood Pressure) Irregular Heart Beat Kidney Disease Liver Disease MVP Or Valvular Disease Osteoarthritis Paralysis Phlebitis Pneumonia Polio Problems Breathing Problems Breathing Problems With Anesthesia Prostate Problems Psychiatric Illness/Depression Recent Cold/Sore Throat/Cough Recent Exposure To A Communicable Disease Rheumatoid Arthritis Rheumatoid Arthritis Seizures/Epilepsy Shortness Of Breath Sickle Cell Disease Significant Weight Loss Or Weight Gain In The Last Year Skin Rash/Skin Conditions Sleep Apnea Snoring Stomach Pain Stroke TB Thyroid Disease/Goiter Urinary Incontinence None of the above Type of cancer and treatment*Have you had* Chronic Pain Diabetes Heart attack/High Blood Pressure Breast Cancer/Colon Cancer Psychiatric Illness/Depression Disability None of the above Medical history commentsFemales onlyFirst day of your last menstrual period Are your periods normal? Yes No Any abnormal vaginal / breast discharge? Yes No Number of pregnancies Number of deliveries Past Surgical HistoryDo you have any past surgical history?* Yes No Please list all the operations you have undergone, including the year they were performed*YearOperation MedicationsDo you take any non-pain medications* Yes No Please list all the non-pain medications you are currently taking, including the dosage.*Do you take any pain medications?* Yes No Please list all the pain medications you are currently taking, including the dosage.*What pain medications have you tried in the past for your pain? Please list all and explain why you no longer taking them.Do you have any drug allergies, sensitivity or reaction?* Yes No Describe Drug Allergies/Sensitivity - Reaction*Environmental / Food Allergies: (iodine, dye, mold, dust, pollen, cats, dogs, eggs…)Family Medical HistoryDo you have any Family Medical History?* Yes No Has anyone in your family had* Asthma/emphysema Hypertension Heart Attacks/Angina Congestive Heart Failure MVP or Valvular Disease Cancer Diabetes Arthritis Depression Sleep Apnea Mental Illness Other Who in family had medical history?* Mother Father Siblings Grandparents Describe other family medical history Personal HabitsDo you smoke?* Yes No How much per day?* Are you a previous smoker?* Do you drink alcohol?* Yes No How much alcohol do you drink? Have you ever had a problem with drugs or alcohol?* Yes No Do you have a history of illicit/street drug use?* Yes No What drugs have you used? How many caffeinated beverages do you consume daily How often do you see a doctor? 3 or more times per month 1 – 2 times per month less than once a month Social/Occupational HistoryMarital StatusSelect one...SingleMarriedDivorcedWidowedSeparatedRemarriedSpouse’s name First Last Number of children? Ages? Who shares your home? Occupation How long at this position? Brief description of job dutiesWork StatusSelect one...Employed Full-TimeEmployed Part-TimeSelf-employedNot employed but looking for workNot employed and not looking for workHomemakerRetiredStudentDisabledIf disabled, date last workedMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If working less than full time is pain the reason? If you had no pain would you return to work? Has your employer been helpful and understanding of your problem? Yes No What would you hope to be the end result of this evaluation? Medical diagnosis Recommendations for surgery Recommendations for medications Recommendations for rehabilitation If you are treated here, what are the results you HOPE for? Pain reduction Increased recreation Improved emotional well- being Increased socialization Return to work If you are treated here, what are the results you EXPECT?Upload your imaging reportsCT scan, X-Rays, MRI written reportsAccepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx, Max. file size: 64 MB.Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx, Max. file size: 64 MB.Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx, Max. file size: 64 MB.Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx, Max. file size: 64 MB.Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx, Max. file size: 64 MB.Additional InformationAppointment Date MM slash DD slash YYYY Appointment Time : Hours Minutes AM PM Pharmacy Name, cross roads and City Advance Directives DNR - Do Not Resuscitate GUARD - Guardianship LW - Living Will POA - Power of Attorney NE - Not Establish
