New Patient Demographics Form

New Patient Demographics Form
How did you hear about us?*
Others: (Please specify)*
Today's Date*

MonthDayYear
Date
Patient's Name*

First NameLast Name
Date of Birth (MM-DD-YYYY)*
Age:
Social Security No.
Gender:*

MaleFemaleOther
Marital Status:*

SingleMarriedDivorcedWidowedOther
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
I agree to receive emails, text messages, and phone calls, which may be recorded and/or sent using automated dialing or emailing equipment or software unless I opt-out from such communications. I also agree to the Terms of Use and Privacy Policy linked below. I understand that my consent to be contacted is not a requirement to purchase any product or service and that I can opt-out at any time. Reply STOP for STOP and HELP for help for more information. Message & data rates may apply. Message frequency varies.*
Email Address:
Occupation:
Employer:
Emergency Contact Name:*
Home Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Please upload or take a photo of your Driver's License or other ID card (Front):

Cancelof
Driver's License or ID card (Front):
REFERRING DOCTOR'S INFORMATION
Referring Doctor's Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
PRIMARY CARE DOCTOR'S INFORMATION
Primary Care Doctor’s Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
PREFERRED PHARMACY INFORMATION
Do you have a preferred pharmacy? If yes, please list them below.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
HEALTH INSURANCE INFORMATION
Primary Insurance Plan Name:*
Primary Insurance ID Number:*
Group Number:
Policy Holder Name:*
Policy Holder Date of Birth:*
Patient’s Relationship to Policy Holder:*
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 upload your insurance ID (Front):

Cancelof
Please upload your insurance ID (Back):

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Insurance ID card (Front):
Insurance ID card (Back):
Other Insurance:
Case Worker/Attorney Name:
Case Worker/ Attorney Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
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.*
MEDICAL HISTORY
Height:
Weight:
Where is your worst area of pain located?*
Does this pain radiate? If yes, where?*
Please list any additional areas of pain.
Approximately when did this pain begin?*
What caused your current pain episode?*

Motor Vehicle AccidentPersonal Injury (legal term describing injury sustained to your person by negligence of another)Other
How did your current pain episode begin?*

GraduallySuddenly
Since your pain began, how has it changed?*

DecreasedIncreasedStayed the same
Please indicate your average daily pain score.*

1

2

3

4

5

6

7

8

9

10

1 is Lowest, 10 is Highest
Please indicate your worst daily pain score.*

1

2

3

4

5

6

7

8

9

10

1 is Lowest, 10 is Highest
Check all that describe your pain.*

AchingCrampingDullTingling/Pins and NeedlesHot/BurningNumbnessShock-likeShootingSpasmingSqueezingSharpThrobbingTiring/Exhausting
What word best describes your pain?*

ConstantIntermittent
When is your pain at its worst?*

MorningDuring the dayEveningsMiddle of the night

Mark the effect of each of the following on your pain:*

Rows	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:*

Fevers/ChillsBladder IncontinenceBowel IncontenenceUnintentional weight lossNumbness/Tingling in the genital regionProgressive WeaknessBalance ProblemsDifficulty WalkingNone
Other Doctors Consulted for your current pain. (Only for pain relief)*

AcupuncturistAnesthesiologistChiropractorDentistEndocrinologistENT PhysicianGeneral PhysicianHypnotistInternistNeurologistNeurosurgeonOphthalmologistOrthopedic SurgeonPain PhysicianPhysical TherapistPlastic SurgeonPodiatristPsychiatrist/PsychologistRheumatologistOther
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.Format: (000) 000-0000.
REVIEW OF SYSTEMS

Please check if you have any of the following symptoms not mentioned above:
General

FeversChillsUnintentional weight loss
Head

HeadachesMigraines
Neck

Neck painTorticollis/twisted neck
Cardio

Chest painRib pain
Gastrointestinal

Fecal IncontinenceAbdominal painGastroparesis
Skin

ShinglesHair LossWorrisome wrinkles on face/eyes
Neurologic

Peripheral neuropathySpasticity
Back

Low BackSpasm
Genitourinary

Numbness in genital regionUrinary incontinenceUrinary retentionPain in genital regionErectile dysfunction
Extremities

Hand PainWrist PainCarpal TunnelShoulder PainElbow PainKnee PainAnkleFoot Pain
Sleep

Obstructive sleep apneaRestless leg syndrome
Hematology

Easy bleedingEasy bruising
Vascular

Varicose veinsSpider veinsUlcers on leg
Psychiatric

PTSDAnxietyBipolar disorderDepressionSchizophrenia
DIAGNOSTIC TESTS AND IMAGING
Did you have any diagnostic tests performed for your current pain complaints?

YesNo
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:

Rows	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.

Rows	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)?*

YesNo
If so, have you ever had any adverse reaction to anesthesia?*

YesNo
From what type of anesthesia did you react adversely to? Please check all that apply.*

Local AnesthesiaEpiduralGeneral AnesthesiaIV SedationNot applicable
Please explain briefly.
Do you have a family history of adverse reactions to anesthesia? If so, to which of the following?*

Local AnesthesiaEpiduralGeneral AnesthesiaIV SedationNot applicable
PAST MEDICAL HISTORY
Please list all of your previous and current medical condition (e.g. Heart attack, asthma, etc.).*
Type "NA" if none.
PAST SURGICAL HISTORY
Have you ever had any surgical procedures done?*

YesNo
Heart Surgery

Valve ReplacementAneurysm RepairStent PlacementVascular SurgeryNot ApplicableOther
If so, please indicate the date, type, and any pertinent details.
Joint Surgery

ShoulderHipKneeNot ApplicableOther
If so, please indicate the date, type, and any pertinent details.
Spine/Back Surgery

DiscectomyLaminectomySpinal FusionNot ApplicableOther
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?*

YesNo
Are you currently taking any blood-thinners or anticoagulants?*

YesNo
If yes, which one?

PlavixCoumadinEliquisAspirinNot ApplicableOther
Please list all medications you are currently taking including the dose and frequency.*
Type "NA" if none.
ALLERGIES
Do you have known drug allergies?*

YesNo
If so, please list all medications you are allergic to and the allergic reaction.*
Topical Allergies

IodineLatexTape
Are you allergic to contrast?*

YesNo
FAMILY HISTORY
Do you have any significant family medical history?*

I have no significant family medical historyI am adopted/No family medical history availableYes I have

Mark all appropriate diagnoses as they pertain to your biological MOTHER AND FATHER only.

Rows	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?*
For Female Only
Could you become pregnant?
For Female Only
If yes, when was your last menstrual period?

MonthDayYear
Do you use tobacco?*
If yes, how much?
Have you ever used illicit drugs?*
If yes, which one?
How often do you have a drink containing alcohol?*

NeverMonthly or less2-4 time a month2-3 times a week4 or more times a weekNot ApplicableOther
How many drinks containing alcohol do you have on a typical day when you are drinking?*

1-27-93-410 or more5-6Other

Please answer the following:*

Rows	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:

Rows	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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New Patient Demographics Form

REFERRING DOCTOR'S INFORMATION

PRIMARY CARE DOCTOR'S INFORMATION

PREFERRED PHARMACY INFORMATION

HEALTH INSURANCE INFORMATION

MEDICAL HISTORY

REVIEW OF SYSTEMS

DIAGNOSTIC TESTS AND IMAGING

INTERVENTIONAL PAIN TREATMENT HISTORY

TREATMENTS FOR PAIN RELIEF

ANESTHESIA HISTORY

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

CURRENT MEDICATIONS

ALLERGIES

FAMILY HISTORY

SOCIAL HISTORY

Please click "Submit" and Do Not Close the Browser Until your submission is received and a "Thank You" message appear.