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?*YesNoAlternate PhoneEmail Birth date* MM DD YYYY Emergency Contact InformationEmergency contact name* First Last Relationship to patientEmergency phone*Can we leave a message?YesNoAlternate emergency phoneInsurance informationName of Subscriber First Last Relationship to patientSelect one...SelfSpouseChildParentOtherSubscriber's date of birth MM DD YYYY Subscriber's employerInsurance CompanyInsurance ID#Group #(on card)Secondary Insurance informationName of Subscriber First Last Relationship to patientSelect one...SelfSpouseChildParentOtherSubscriber's date of birth MM DD YYYY Subscriber's employerInsurance CompanyInsurance ID#Group #(on card)Other Insurance informationType of InsuranceSelect one...Workman's CompensationAuto InsuranceClaim #Claim adjuster nameClaim adjuster phoneClaim 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 circumstancesPlace of employmentDate of injury Date Format: MM slash DD slash YYYY Type of workWhat 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 painAssociated 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*YesNoHow long, was it helpful?*Date of last treatment / use*Biofeedback*YesNoHow long, was it helpful?*Date of last treatment / use*Chiropractor*YesNoHow long, was it helpful?*Date of last treatment / use*Heat*YesNoHow long, was it helpful*Date of last treatment / use*Hypnosis*YesNoHow long, was it helpful*Date of last treatment / use*Ice*YesNoHow long, was it helpful*Date of last treatment / use*Illicit (street drugs)*YesNoHow long, was it helpful*Date of last treatment / use*Massage*YesNoHow long, was it helpful*Date of last treatment / use*Prescribed pain medicine*YesNoHow long, was it helpful*Date of last treatment / use*Physical therapy*YesNoWhere did you goHow long, was it helpful*Date of last treatment / use*Nerve blocks*YesNoHow long, was it helpful*Date and location of injections*Therapy/counseling*YesNoHow long, was it helpful*Date of last treatment / use*Surgery*YesNoHow long, was it helpful*Date of surgeries*Steroid treatment*YesNoHow long, was it helpful*Date and location of last treatment*TENS*YesNoHow long, was it helpful*Date of last treatment / use*Procedure/injection*YesNoHow long, was it helpfulDate 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 periodAre your periods normal?YesNoAny abnormal vaginal / breast discharge?YesNoNumber of pregnanciesNumber of deliveriesPast Surgical HistoryDo you have any past surgical history?*YesNoPlease list all the operations you have undergone, including the year they were performed*YearOperation MedicationsDo you take any non-pain medications*YesNoPlease list all the non-pain medications you are currently taking, including the dosage.*Do you take any pain medications?*YesNoPlease 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?*YesNoDescribe Drug Allergies/Sensitivity - Reaction*Environmental / Food Allergies: (iodine, dye, mold, dust, pollen, cats, dogs, eggs…)Family Medical HistoryDo you have any Family Medical History?*YesNoHas 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?*YesNoHow much per day?*Are you a previous smoker?*Do you drink alcohol?*YesNoHow much alcohol do you drink?Have you ever had a problem with drugs or alcohol?*YesNoDo you have a history of illicit/street drug use?*YesNoWhat drugs have you used?How many caffeinated beverages do you consume dailyHow often do you see a doctor?3 or more times per month1 – 2 times per monthless than once a monthSocial/Occupational HistoryMarital StatusSelect one...SingleMarriedDivorcedWidowedSeparatedRemarriedSpouse’s name First Last Number of children?Ages?Who shares your home?OccupationHow 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 workedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If 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?YesNoWhat 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.Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx.Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx.Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx.Accepted file types: doc, docx, pdf, txt, zip, jpeg, jpg, png, xls, xlsx.Additional InformationAppointment Date Date Format: MM slash DD slash YYYY Appointment Time : HH MM AM PM Pharmacy Name, cross roads and CityAdvance DirectivesDNR - Do Not ResuscitateGUARD - GuardianshipLW - Living WillPOA - Power of AttorneyNE - Not Establish
