New Patient Demographics Form
How did you hear about us?
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Please Select
Insurance Referral
Website: https://crissp.net/
Family or Friend's Recommendation
Other
Others: (Please specify)
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Today's Date
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Month
-
Day
Year
Date
Patient's Name
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First Name
Last Name
Date of Birth (MM-DD-YYYY)
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Age:
Social Security No.
Gender:
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Male
Female
Other
Marital Status:
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Single
Married
Divorced
Widowed
Other
Home Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number:
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Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Email Address:
Occupation:
Employer:
Emergency Contact Name:
*
Home Phone Number:
*
Please enter a valid phone number.
Relationship:
Please upload or take a photo of your Driver's License or other ID card (Front):
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Driver's License or ID card (Front):
REFERRING DOCTOR'S INFORMATION
Referring Doctor's Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
PRIMARY CARE DOCTOR'S INFORMATION
Primary Care Doctor’s Name:
First Name
Last Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
PREFERRED PHARMACY INFORMATION
Do you have a preferred pharmacy? If yes, please list them below.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
HEALTH INSURANCE INFORMATION
Primary Insurance Plan Name:
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Primary Insurance ID Number:
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Group Number:
Policy Holder Name:
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Policy Holder Date of Birth:
*
Patient’s Relationship to Policy Holder:
*
Please Select
Self
Spouse
Child
Other
Please upload or take a photo of your Insurance ID card (Front):
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Please upload or take a photo of your Insurance ID card (Back):
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Insurance ID card (Front):
Insurance ID card (Back):
Secondary Insurance Plan Name:
Secondary Insurance ID Number:
Group Number:
Policy Holder Name:
Policy Holder Date of Birth:
Patient’s Relationship to Policy Holder:
Please Select
Self
Spouse
Child
Other
Please upload your insurance ID (Front):
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Please upload your insurance ID (Back):
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Insurance ID card (Front):
Insurance ID card (Back):
Other Insurance:
Please Select
Self Pay
Workers Compensation
Motor Vehicle Accident
Personal Injury
Not Applicable
Other
Case Worker/Attorney Name:
Case Worker/ Attorney Phone Number:
Please enter a valid phone number.
Date of Injury:
Claim Number:
AUTHORIZATION & ASSIGNMENT OF BENEFITS: I, the undersigned hereby authorize the performance of such services deemed medically necessary to diagnose and treat my condition(s). Further, I authorize my insurance benefits to be paid directly to the Center for Regenerative and Interventional Spine and Sports Pain (CRISSP). I understand that I am financially responsible for any co-payments, deductibles or uncovered amounts. I authorize CRISSP to release any information necessary for the purpose of processing claims with my insurance company. I hereby order all parties to accept a copy of this authorization in lieu of the original.
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MEDICAL HISTORY
Height:
Weight:
Where is your worst area of pain located?
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Does this pain radiate? If yes, where?
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Please list any additional areas of pain.
Approximately when did this pain begin?
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What caused your current pain episode?
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Motor Vehicle Accident
Personal Injury (legal term describing injury sustained to your person by negligence of another)
Other
How did your current pain episode begin?
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Gradually
Suddenly
Since your pain began, how has it changed?
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Decreased
Increased
Stayed the same
Please indicate your average daily pain score.
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Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
Please indicate your worst daily pain score.
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Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
Check all that describe your pain.
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Aching
Cramping
Dull
Tingling/Pins and Needles
Hot/Burning
Numbness
Shock-like
Shooting
Spasming
Squeezing
Sharp
Throbbing
Tiring/Exhausting
What word best describes your pain?
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Constant
Intermittent
When is your pain at its worst?
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Morning
During the day
Evenings
Middle of the night
Mark the effect of each of the following on your pain:
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Increases my pain
Decreases my pain
No change in my pain
Bending Forward
Bending Backward
Changes in Weather
Climbing Stairs
Walking
Lifting Objects
Lying on your Back
Lying on your Stomach
Rising from a Sitting Position
Sitting
Standing
Driving
Coughing/Sneezing
Other Activities:
In the past three months, have you developed any new:
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Fevers/Chills
Bladder Incontinence
Bowel Incontenence
Unintentional weight loss
Numbness/Tingling in the genital region
Progressive Weakness
Balance Problems
Difficulty Walking
None
Other Doctors Consulted for your current pain. (Only for pain relief)
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Acupuncturist
Anesthesiologist
Chiropractor
Dentist
Endocrinologist
ENT Physician
General Physician
Hypnotist
Internist
Neurologist
Neurosurgeon
Ophthalmologist
Orthopedic Surgeon
Pain Physician
Physical Therapist
Plastic Surgeon
Podiatrist
Psychiatrist/Psychologist
Rheumatologist
Other
If you saw a physical therapist, when did you go and for how long?
If you saw a Chiropractor, when did you go and for how long?
Chiropractor's Name:
Chiropractor's Contact Number:
Please enter a valid phone number.
REVIEW OF SYSTEMS
Please check if you have any of the following symptoms not mentioned above:
General
Fevers
Chills
Unintentional weight loss
Head
Headaches
Migraines
Neck
Neck pain
Torticollis/twisted neck
Cardio
Chest pain
Rib pain
Gastrointestinal
Fecal Incontinence
Abdominal pain
Gastroparesis
Skin
Shingles
Hair Loss
Worrisome wrinkles on face/eyes
Neurologic
Peripheral neuropathy
Spasticity
Back
Low Back
Spasm
Genitourinary
Numbness in genital region
Urinary incontinence
Urinary retention
Pain in genital region
Erectile dysfunction
Extremities
Hand Pain
Wrist Pain
Carpal Tunnel
Shoulder Pain
Elbow Pain
Knee Pain
Ankle
Foot Pain
Sleep
Obstructive sleep apnea
Restless leg syndrome
Hematology
Easy bleeding
Easy bruising
Vascular
Varicose veins
Spider veins
Ulcers on leg
Psychiatric
PTSD
Anxiety
Bipolar disorder
Depression
Schizophrenia
DIAGNOSTIC TESTS AND IMAGING
Did you have any diagnostic tests performed for your current pain complaints?
Yes
No
MRI
Please indicate the Date and Facility
X-ray
Please indicate the Date and Facility
CT scan
Please indicate the Date and Facility
EMG/NCV
Please indicate the Date and Facility
Others
Please indicate the Date and Facility
INTERVENTIONAL PAIN TREATMENT HISTORY
Mark all of the following interventional pain treatments you have undergone prior to today’s visit:
Cervical
Thoracic
Lumbar
Not Applicable
Discogram
Epidural Steroid Injection
Medial Branch Blocks or Facet Injections
Radiofrequency Ablation
Spinal Column Stimulator
Joint Injection –Joint(s)
Nerve Blocks - Area/Nerve(s)
Trigger Point Injection – Where?
Vertebroplasty/Kyphoplasty–Level(s)
Other
TREATMENTS FOR PAIN RELIEF
Please mark all of the following treatments you have used for pain relief.
Helped Pain
Worsen
No Change
Acupuncture
Biofeedback
Brace Support
Chiropractic Treatment
Hot/Cold Packs
Injection Therapy
Massage Therapy
Medications
Physical Therapy
TENS Unit
Traction
ANESTHESIA HISTORY
Have you ever had anesthesia (Sedation for a surgical procedure)?
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Yes
No
If so, have you ever had any adverse reaction to anesthesia?
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Yes
No
From what type of anesthesia did you react adversely to? Please check all that apply.
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Local Anesthesia
Epidural
General Anesthesia
IV Sedation
Not applicable
Please explain briefly.
Do you have a family history of adverse reactions to anesthesia? If so, to which of the following?
*
Local Anesthesia
Epidural
General Anesthesia
IV Sedation
Not applicable
PAST MEDICAL HISTORY
Please list all of your previous and current medical condition (e.g. Heart attack, asthma, etc.).
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Type "NA" if none.
PAST SURGICAL HISTORY
Have you ever had any surgical procedures done?
*
Yes
No
Heart Surgery
Valve Replacement
Aneurysm Repair
Stent Placement
Vascular Surgery
Not Applicable
Other
If so, please indicate the date, type, and any pertinent details.
Joint Surgery
Shoulder
Hip
Knee
Not Applicable
Other
If so, please indicate the date, type, and any pertinent details.
Spine/Back Surgery
Discectomy
Laminectomy
Spinal Fusion
Not Applicable
Other
If so, please indicate the date, type, and any pertinent details.
Do you have any other surgeries done?
If so, please indicate the date, type, and any pertinent details.
CURRENT MEDICATIONS
Are you currently taking any medications?
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Yes
No
Are you currently taking any blood-thinners or anticoagulants?
*
Yes
No
If yes, which one?
Plavix
Coumadin
Eliquis
Aspirin
Not Applicable
Other
Please list all medications you are currently taking including the dose and frequency.
*
Type "NA" if none.
ALLERGIES
Do you have known drug allergies?
*
Yes
No
If so, please list all medications you are allergic to and the allergic reaction.
*
Topical Allergies
Iodine
Latex
Tape
Are you allergic to contrast?
*
Yes
No
FAMILY HISTORY
Do you have any significant family medical history?
*
I have no significant family medical history
I am adopted/No family medical history available
Yes I have
Mark all appropriate diagnoses as they pertain to your biological MOTHER AND FATHER only.
Arthritis
Cancer
Diabetes
Headaches
Heart Disease
High Blood Pressure
High Cholesterol
Kidney Problem
Liver Problems
Osteoporosis
Rheumatoid Arthritis
Seizure
Stroke
Father
Mother
SOCIAL HISTORY
Occupation
Employer
Are you pregnant?
*
Please Select
Yes
No
Not Applicable
For Female Only
Could you become pregnant?
Please Select
Yes
No
Not Applicable
For Female Only
If yes, when was your last menstrual period?
-
Month
-
Day
Year
Do you use tobacco?
*
Please Select
Yes
No
If yes, how much?
Have you ever used illicit drugs?
*
Please Select
Yes
No
If yes, which one?
How often do you have a drink containing alcohol?
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Never
Monthly or less
2-4 time a month
2-3 times a week
4 or more times a week
Not Applicable
Other
How many drinks containing alcohol do you have on a typical day when you are drinking?
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1-2
7-9
3-4
10 or more
5-6
Other
Please answer the following:
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Never
Less than monthly
Monthly
Weekly
Daily or Almost
How often do you have 6 or more drinks on one occasion?
How often during the last year have you found that you were not able to stop drinking once you had started?
How often during the last year have you failed to do what was normally expected of because of drinking?
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
How often during the last year have you had a feeling of guilt or remorse after drinking?
How often during the last year have you been unable to remember what happened the night before because of your drinking?
Please answer the following:
No
Yes, but not in the last year
Yes, during the last year
How you or someone else been injured because of your drinking?
Has a relative, friend, doctor or other health care worker been concerned about your drinking or suggested you cut down?
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