Spine and Pain Associates - New Patient Forms

Date
First Name
Middle
Last
Name you wish to be called in the office
Age
Date of Birth

MonthDayYear
MaleFemale
Address
City
State
Zip
Telephone Home
Work
Cell
Email
example@example.com
Race

WhiteHispanicAfrican-AmericanAsianNative AmericanDeclineOther
Primary Language (if not English)
Referred By: Whom may we thank for referring you to our practice?
Physician Name:
Website: (please list which one)
Insurance Company Listing
Other
Emergency Contact
Relationship
Home Phone
Cell Phone
Advanced Directive

NoneLiving Will
Healthcare POA/Proxy:
Marital Status

MarriedSingleWidowedDivorced
Education: Highest education level achieved

Post graduateCollege graduateHigh school graduate/GEDOther
Employment

Full-timePart-timeRetiredStudentHomemakerDisabledUnemployedWork Restriction: YesWork Restriction: No
Occupation
Employer Name
Address
Name of Contact person: First and Last Name
Phone Number
Fax Number
Reason for Visit Today
Reason for Visit Today
Pain severity with 0 being no pain and 10 being severe pain:
Current
Average pain over the last month:
The last month
Worst pain
Least pain
When did symptoms begin?

Post-surgeryMedical IllnessFallAuto AccidentWork injury/DateOther
Pain Quality - check all that apply

Dull/AchingNumbness/TinglingShooting/StabbingStinging/Burning/HotThrobbing
Do the symptoms radiate?

YesNo
If so, where?
Additional symptoms

SpasmStiffnessSwellingItchingRestless legTendernessLoss of Balance
Pain Pattern
Current pain began

GraduallySuddenly
Pain occurs

ConstantlyOccasionallyWorse in morningWorse at nightWorse with activity
Since pain began, it has

DecreasedIncreasedStayed the same
Pain is Worse with

RestActivityWeather ChangeBending ForwardBending BackwardOverhead ActivityClimbing StepsLimb PositionCoughing/SneezingSit to StandLying DownLiftingTwistingTurning HeadSitting/DrivingStandingWalkingRunningOther
Pain Improves with

RestActivityColdHeatChiropracticPosition changeTENsExerciseMassage
Injections
Medication
Treatment History
No prior treatments for current symptomsAcupunctureBraceChiropractorInjectionsMassagePhysical TherapyTENs unitOther
When, how long
Helped (Yes/No)
Facility/Provider
Type of consultations

Spine SurgeonOrthopedic SurgeonPain SpecialistNeurologistRheumatologistPodiatristPsychiatristPsychologist
Facility/Provider
Date / Timeframe
Medications - Check all medications that you have tried for pain control
Over the counter

Acetaminophen (Tylenol)AspirinIbuprofenNaprosynPatchesCreams/OintmentsOther
Muscle Relaxers

Cyclobenzaprine (Flexeril)Methocarbamol (Robaxin)BaclofenTizanidine (Zanaflex)Metaxolone (Skelaxin)Chlorzoxazone (Lorzone)Diazepam (Valium)Carisoprodol (Soma)
Neuromodulating

Gabapentin (Neurontin)HorizantGraliseAmitriptyline (Elavil)Pregabalin (Lyrica)Duloxetine (Cymbalta)Other
Opiates

Codeine (e.g Tyl #3)Tramadol (Ultram/Ultracet)Hydrocodone (Norco, Lortab, etc)Oxycodone (Percocet, etc)Morphine SulfateHydromorphone (Dilaudid)Oxymorphone (Opana)Tapentadol (Nucynta)Other
Long-Acting Opiates:
Diagnostic Tests/ Imaging Studies

X-rayCT ScanMyelogramMRIDEXA ScanBone ScanEMG/NCSNoneOther
Body Site
Date
Facility
Medical History Medical Conditions - Check all conditions that have been diagnosed in the past
General/Medical

HIV/AIDSHypothyroidHyperthyroid
Cancer - Type:
Diabetes - Type:
Gastrointestinal

Acid Reflux/GERDBowel IncontinenceCirrhosis/Liver FailureConstipationCrohn’s Disease/ Ulcerative ColitisIrritable Bowel Syndrome (IBS)
GI Bleeding, When?
Hepatitis - Type:
Neurologic

Dementia/Alzheimer’sMultiple SclerosisNeuropathySeizure/EpilepsySpinal Cord InjuryStroke/TIA
HEENT

CataractsGlaucomaHeadachesHead Injury
Musculoskeletal

Amputation/Phantom Limb PainCarpal Tunnel SyndromeCompression Fracture(s)Connective Tissue DiseaseFibromyalgiaGoutJoint Disease/OsteoarthritisOsteoporosisRheumatoid Arthritis
Cardiovascular

Coronary Artery DiseaseCongestive Heart FailureHigh Blood Pressure (HTN)High CholesterolIrregular Heart Beat
Heart Attack (MI), When?
Genitourinary/Kidney

Bladder/Kidney InfectionsChronic Kidney DiseaseDialysisKidney StonesProstate EnlargementUrinary Incontinence
Respiratory

AsthmaBronchitisEmphysema/COPDSinusitisSleep ApneaTuberculosis
Hematologic

AnemiaBleeding DisorderBlood ClotPeripheral Vascular Disease
Psychiatric

AnxietyBipolar DisorderDepressionSchizophreniaSubstance AbuseOther
Please list all current medications, including over the counter medications, supplements and vitamins.
Medication, Dose and Frequency
Blood Thinners (Anticoagulants) Check all medications that you are currently taking

Not on any blood thinnersAggrenoxCoumadin (Warfarin)EffientEliquisLovenoxPlavixPradaxaXareltoOther
Drug Allergies

No known drug allergies
Medication/Reaction
Are you allergic to any of the following?

Betadine/lodineLatexIV Contrast and/or DyeShellfishTape
Past Surgical History

I have not had any surgical procedures
Abdominal Surgery:

AppendectomyGallbladder RemovalOther
Heart Surgery

Aneurysm RepairCoronary BypassStent PlacementValve ReplacementOther
Female Surgeries

Caesarean SectionHysterectomyLaparoscopyOvarian
Joint Surgery

HipKneeShoulderOther
Other Common Surgeries

Hemorrhoid SurgeryHernia RepairThyroidectomyTonsillectomyVascular Surgery
Spine/Back Surgery

Discectomy (Please use box below)Laminectomy (Please use box below)Spinal Fusion (Please use box below)Other (Please use box below)
Please list any other surgeries and dates
Family History

Anxiety/DepressionHeart Disease/StrokeLiver ProblemsArthritisHeadachesRheumatoid ArthritisCancerHigh Blood PressureSeizuresDiabetesKidney ProblemsSubstance AbuseI have no significant family medical historyI am adopted and no medical history is available
Social History
Alcohol Use

NeverSocial Alcohol UseDailyHistory of Alcoholism
Smoker or Tobacco Use

NeverOccasionalCurrent UserFormer User
Drug Use

I am currently using illegal drugs, list (Please use box below):I am currently using someone else's prescription medications, list (Please use box below)I formerly used illegal drugs (not currently using), list (Please use box below)I have abused narcotic or prescription medications in the past, list (Please use box below)I have been treated in a Detox program (Please use box below)i have never used any drugs illegaly
Review of Systems
Constitutional/ Systemic:

Chills/Night SweatsDifficulty SleepingEasy BruisingFeversWeight LossWeight Gain
Endocrine

Fatigue/Low EnergyHeat/Cold IntoleranceIncreased ThirstLow Libido
Genitourinary/Nephrology

Frequent UrinationIncontinencePainful UrinationPelvic Pain
Eyes/Ears/Nose/Throat/Neck

Allergies/Runny NoseDifficulty HearingEaraches/RingingNosebleedsRecent Visual ChangesRecurrent Sore ThroatsSinus Problems
Cardiorespiratory:

Chest PainEdema/Swelling in the FeetHigh Blood PressureLightheadednessPalpitationsShortness of Breath
Neurological:

DizzinessHeadachesImbalanceLoss of MemoryNumbness/TinglingSeizuresWeakness
Gastrointestinal

ConstipationDiarrheaNausea/VomitingReflux
Psychiatric

Anxiety/StressDepressed MoodHallucinationsSuicidal PlanningSuicidal Thoughts
Should be Empty: