First & Last Name
*
Preferred Name
Age
*
Date of Birth
*
Please select a month
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Year
Gender
*
Male
Female
Decline to specify
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Have you been scheduled for your new appointment by one of our staff members?
*
Yes
No
One of our staff members will contact you after you complete this form. Please proceed. Thank you.
Who referred you to our practice?
*
Who is your primary care physician?
*
Would you like us to keep any other doctors informed of your care?
*
Yes
No
What is his/her name?
What is his/her specialty?
Please Select
Family Practice
Internal Medicine
Neurosurgery
Neurology
Orthopedics
Rheumatology
Chiropractic
Physical Medicine & Rehabilitation
Other
Our practice specializes in minimally-invasive procedures (injections for pain). These procedures target the cause of your pain. We are currently not accepting patients for medication management only. Are you open to injections as a treatment approach?
*
Yes, I am open to procedures as an option
No, I am not open to procedures as an option
Tell Us About Your Pain
Where is your pain located?
*
Back
Low Back
Leg(s)
Arm(s)
Shoulder(s)
Neck
Headaches
Foot or Feet
Buttock(s)
Hip(s)
Other
Does your pain radiate or travel from one location to another?
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Yes
No
If so, please describe
When did your pain start?
*
How did your pain start?
*
Non Injury Related
Injury at work
Injury, not at work
Motor Vehicle Accident
Caused by treatment (i.e. surgery)
If injury, date of injury
Do you have a workers comp case?
Yes
No
Is there an open No Fault case?
Yes
No
Name of No Fault Insurance Company?
Describe your pain
*
Burning
Stabbing
Sharp
Throbbing
Shooting
Dull, aching
Pressure
Pins/needles
Other
Zero being no pain and ten being the worst pain you have experienced, what # is your pain now?
*
0
1
2
3
4
5
6
7
8
9
10
Your current pain level
Zero being no pain and ten being the worst pain you have experienced, what # is your pain now?
10
9
8
7
6
5
4
3
2
1
0
How often do you have the pain?
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Constantly
Most of the time
Intermittently
Occasionally
In general, during the past month when has your pain been the worst?
*
Morning
Afternoon
Evening
Night
No pattern
Alleviating/Exacerbating Factors
My pain is (select a choice for each activity) when I ...........
*
Worse
Same
Better
N/A
Lay Down
Stand
Exercise
Walk
Take medications
Relax
Think about something else
Cough/Sneeze
Urinate
Have a bowel movement
Activities of Daily Living
During the past month, my pain has affected my .............
*
Personal Care
Lifting
Walking
Sitting
Standing
Sleeping
Sex Life
Social Life
Traveling
Mood
Driving
Reading
Concentration
Recreational activities
Previous Pain Interventions
Please indicate if you have had any of the following treatments for your current pain and what the results were:
*
Never tried
No relief
Some Relief
Moderate Relief
Excellent Relief
Acupuncture
Chiropractic
Cold
Exercise
Heat
Injections
Over-the-counter meds
Prescription Meds
Physical Therapy
TENS Unit
Traction
If you have had previous injections for current pain what facility did you have them done?
How long did the injections provide relief?
If you tried chiropractic care when did your care begin and end? (Dates must be provided please) If undergoing chiropractic care please write "current" as your end date.
Name of chiropractor or chiropractic clinic?
If you tried physical therapy when did your therapy begin and end? (Dates must be provided please) If undergoing physical therapy please write "current" as your end date.
Name of the physical therapy facility?
Imaging Studies
Please list any imaging studies (MRI, CT Scan, X-Ray, EMG) you have undergone for your current pain problem. Please include where the study was performed. Separate each by a comma (,).
Medical History
Do you currently have any of the following health problems other than pain?
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Acid Reflux
Angina
Asthma
Anxiety
Arthritis
Bleeding Problems
Blood Disorder
Breathing Problems
Cancer
Chest Pressure
Chronic Cough
Depression
Heart Disease
High Blood Pressure
Hyperthyroidism
Kidney Disease
Neurological
Stomach Problems
Liver Disorder
Seizures or Epilepsy
Stroke
None
Other
Surgical History
Please describe all surgeries you have undergone (separate each surgery by a comma (,).
Medications
Name of Pharmacy (if applicable)
Street Address and City Where Pharmacy is Located
Please list pain medications you take (separate each by a comma (,) and include dose and how often you take it)
Are you currently being prescribed a controlled prescriptive medication such as hydrocodone, fentanyl, hydromorphone, morphine, oxycodone?
Yes
No
If so, have your bowel habits changed since starting the controlled substance?
Yes
No
Not applicable
Please list any previous medications you have tried for pain:
Please list any other medications you currently take. If none, write "None."
*
Allergies
Do you have any known drug Allergies including dye or contrast?
*
Yes
No
If so, please list allergies below:
Psychological Treatments
Have you ever had psychiatric, psychological or social work evaluations or treatment for any problem, including your current pain?
*
Yes
No
If so, please describe the treatment and when you have the treatment:
Have you ever considered suicide?
Yes
No
Do you have members of your family who have committed suicide?
Yes
No
Do you have members of your family who have had psychiatric illness?
Yes
No
Family History
My biological father is .............
*
Alive
Deceased
Unknown
If deceased, what was the cause of death?
Please indicate health problems your biological father has or had?
Acid Reflux
Angina
Asthma
Anxiety
Arthritis
Bleeding Problems
Blood Disorder
Breathing Problems
Cancer
Chest Pressure
Chronic Cough
Depression
Heart Disease
High Blood Pressure
Hyperthyroidism
Kidney Disease
Neurological
Pain
Stomach Problems
Liver Disorder
Seizures or Epilepsy
Stroke
Unknown
My biological mother is .............
*
Alive
Deceased
Unknown
If deceased, what was the cause of death?
Please indicate health problems your biological mother has or had?
Acid Reflux
Angina
Asthma
Anxiety
Arthritis
Bleeding Problems
Blood Disorder
Breathing Problems
Cancer
Chest Pressure
Chronic Cough
Depression
Heart Disease
High Blood Pressure
Hyperthyroidism
Kidney Disease
Neurological
Pain
Stomach Problems
Liver Disorder
Seizures or Epilepsy
Stroke
Unknown
Social History
What is your legal marital status?
*
Single
Married
Divorced
Separated
Widowed
Who do you live with?
*
Self
Spouse/Partner
Spouse/Partner & children
Children
Friends
Others
Level of Education?
*
College Graduate
High School
GED
Partial High School
Partial College
Vocational School
Employment Status?
*
Employed Full-time
Employed Part-Time
Unemployed
Unemployed due to illness
Retired
If you are employed, what is your occupation?
Does your work involve physical labor?
Yes
No
Do you engage in regular exercise?
*
Yes, I exercise regularly
No, I do not exercise regularly
SMOKING status?
*
I currently smoke
I do not smoke
I am a former smoker
ALCOHOL use?
*
I do drink alcohol
I do not drink alcohol
I no longer drink alcohol
How many beers per week do you consume?
*
0 beers per week
1-3 beer per week
4-6 beers per week
7-10 beers per week
11-14 beers per week
15+ beers per week
How many glasses of wine per week do you consume?
*
0 glasses of wine per week
1-3 glasses of wine per week
4-6 glasses of wine per week
7-10 glasses of wine per week
11-14 glasses of wine per week
15+ glasses of wine per week
How many other drinks containing liquor per week do you consume?
*
0 other drinks per week
1-3 other drinks per week
4-6 other drinks per week
7-10 other drinks per week
11-14 other drinks per week
15+ other drinks per week
Do you use illegal drugs?
*
Yes, I use illegal drugs
No, I do not use illegal drugs
If yes, what drugs?
Have you ever been in a detoxification program for drug abuse or alcoholism?
*
Yes, for drug abuse
Yes, for alcoholism
No
Race (may chose more than one)
*
Black/African American
American Indian/Alaska Native
Asian
Native Hawaiian/Other Pacific Islander
Other
Decline to Specify
Ethnicity
*
Hispanic/Latino
Not Hispanic/Latino
Decline to Specify
None
How did you first hear about our practice?
*
Friend/Family Member
TV Ad
Internet Search
Insurance Company
My Doctor
Magazine Ad
If you answered 'Yes' to an open Workers Comp Case you will be redirected to another form that must be completed. Please complete the form. Thank you
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