Language
English (US)
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Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Insurance Type
Please Select
Medicare
Anthem Blue Cross
Aetna
Cigna
United HealthCare (UHC)
Blue Shield
Health Net
Physicians Medical Group (PMG)
SCCIPA
Worker's Compensation
Personal Injury Lien
NO INSURANCE (CASH-PAY)
OTHER
How Were You Introduced To Allied Pain & Spine Institute?
Please Select
Website
Primary care provider
Surgeon
Chiropractor
Yelp
Google
Family and friends
Insurance Company
Lawyer
Other
Please Provide Referring Doctor’s Name/Information:
*
Please Provide Personal Injury or Work Comp Lawyer's Name/Information (If Applicable):
*
HISTORY of PAIN or INJURY
PRIMARY CARE PROVIDER:
First Name
Last Name
Height in inches:
Weight in lbs:
SYMPTOMATIC LOCATION(S):
*
Head and Face
Spine
Upper Extremities (Arms)
Lower Extremities (Legs)
Other
SPECIFIC PART(S) OF HEAD AND FACE AFFECTED:
Forehead (RIGHT)
Forehead (LEFT)
Face (RIGHT)
Face (LEFT)
Jaw (RIGHT)
Jaw (LEFT)
Temple (RIGHT)
Temple (LEFT)
Back side of head
Top of head
Entire head
Other
SPECIFIC PART(S) OF SPINE AFFECTED:
*
Neck/Upper back (LEFT side only)
Neck/Upper back (RIGHT side only)
Neck/upper back (EQUALLY affected on BOTH sides)
Neck/Upper back (L>R)
Neck/Upper back (R>L)
Neck/Upper back (midline)
Mid back (LEFT)
Mid back (RIGHT)
Low back (LEFT side only)
Low back (RIGHT side only)
Low back (EQUALLY affected on BOTH sides)
Low back (L>R)
Low back (R>L)
Low back (midline)
Tail bone
Other
SPECIFIC PART(S) OF UPPER EXTREMITIES AFFECTED:
*
Arm (LEFT)
Arm (RIGHT)
Shoulder (LEFT)
Shoulder (RIGHT)
Elbow (LEFT)
Elbow (RIGHT)
Forearm (LEFT)
Forearm (RIGHT)
Hand/Wrist (LEFT)
Hand/Wrist (RIGHT)
Other
SPECIFIC PART(S) OF LOWER EXTREMITIES AFFECTED:
*
Leg (LEFT)
Leg (RIGHT)
Buttock (LEFT)
Buttock (RIGHT)
Groin (LEFT)
Groin (RIGHT)
Hip (RIGHT)
Knee (LEFT)
Knee (RIGHT)
Shin (LEFT)
Shin (RIGHT)
Ankle/Foot (LEFT)
Ankle/Foot (RIGHT)
Other
CONDITION IS RELATED TO:
*
Trauma or injury (not related to work or automobile )
Work injury
Motor Vehicle Accident (MVA)
Other (description):
DESCRIPTION OF TRAUMA OR INJURY THAT CAUSED PAIN :
*
WORK INJURY- DATE:
*
-
Month
-
Day
Year
Date
HOW DID WORK INJURY OCCUR?
*
MOTOR VEHICLE ACCIDENT (MVA)- DATE:
*
-
Month
-
Day
Year
Date
DETAILS OF MVA (CAR ACCIDENT) FROM PATIENT STANDPOINT:
*
Driver
Passenger
Wearing seatbelt
Not wearing seatbelt
Rear-ended
T-bone collision
Side-to-side collision
Front-end collision
Air bags deployed
Loss of conciousness
No loss of conciousness
Total loss of vehicle
Emergency or urgent care provided
Other
SYMPTOM CHARACTERISTICS AT INVOLVED BODY PARTS:
*
Aching
Sharp
Pins/Needles at affected limb(s)
Spasms
Tightness/Stiffness
Cramping
Electric
Throbbing
Numbness
Burning
Weakness
Other
HOW QUICKLY DID SYMPTOMS DEVELOP?
*
Suddenly
Gradually
Other
HOW HAVE SYMPTOMS CHANGED OVER TIME?
*
Stayed same
Improved
Worsened
Other
HOW LONG HAS PRIMARY PAIN PROBLEM OR SYMPTOM(S) BEEN PRESENT?
*
Days
Less than 1 month
Less than 2 months
Less than 3 months
3+ months
6+ months
9+ months
1+ year
2+ years
3+ years
4+ years
5+ years
10+ years
Since Injury
Other
TIMELINE(S) FOR SECONDARY OR OTHER PAIN ISSUE (AS APPLICABLE):
DOES PAIN RADIATE OR MOVE TO OTHER AREA(S):
*
No
Yes, pain spreads to:
ON A SCALE OF 0-10, WITH 10 BEING MOST SEVERE PAIN, HOW INTENSE ARE SYMPTOMS ON AVERAGE?
*
0/10 (no pain)
+1/10
+2/10
+3/10
+4/10
+5/10
+6/10
+7/10
+8/10
+9/10
+10/10
HOW FREQUENTLY ARE SYMPTOMS PRESENT?
*
Constantly
Intermittently
Other
HAS PAIN LIMITED FUNCTION?
*
Not at all
Slightly
Moderately
Markedly
Other
ALLEVIATING AND/OR EXACERBATING FACTORS ASSOCIATED WITH CURRENT SYMPTOMS INCLUDE:
*
None
Increased pain with lifting, pushing, pulling
Worse with sleep
Better with rest
Worse with walking
Better with walking
Worse with standing
Better with standing
Worse with exercise
Better with exercise
Worse with sitting
Better with sitting
Worse with arising in the morning
Better as day progresses
Worse with work at desk
Increased pain with bending forward
Increased pain with arching of back
Increased pain repetitive or computer work
Abnormal weight loss
Bowel or bladder dysfuction
Fever
Other
ORAL MEDICATION(S) USED TO MANAGE PAIN BEFORE CONSULTATION AT ALLIED PAIN & SPINE INSTITUTE:
*
None
Tylenol
Non-steroidal anti-inflammatory agent (such as ibuprofen or equivalent)
Muscle relaxers
Opioids
Anti-depressants
Cymbalta
Steroids
Neurontin (Gabapentin)
Lyrica (Pregabalin)
Other
THERAPY AND OTHER CONSERVATIVE TREATMENT(S) TRIED FOR CURRENT COMPLAINT(S) BEFORE CONSULTATION AT ALLIED PAIN & SPINE INSTITUTE:
*
None
Physical therapy
Chiropractic
Acupuncture
Home exercise
Cognitive behavioral therapy
Virtual therapy
Biofeedback
Massage
Yoga
Brace support
Hot/Cold packs
TENS
Other
THERAPY SESSIONS OVER LAST 6 WEEKS:
HAVE ANY INJECTION AND/OR MINIMALLY INVASIVE PROCEDURES BEEN TRIED PRIOR TO ALLIED PAIN & SPINE INSTITUTE?:
*
None
Yes, type/date:
HAS ANY SURGERY BEEN PERFORMED FOR CURRENT ISSUE:
*
No
Yes, type/date:
PREVIOUS DIAGNOSTIC STUDIES FOR STATED CONDITION INCLUDE:
*
None
Unknown
MRI head
MRI neck
MRI midback
MRI low back
MRI of affected joint/extremity
CT head
CT neck
CT midback
CT low back
CT of affected joint/extremity
X-ray of neck
X-ray of midback
X-ray of low back
X-ray of affected joint/body part(s)
EMG/NCS upper extremities
EMG/NCS lower extremities
Other
NAME OF THE FACILITY WHERE IMAGING WAS PERFORMED:
*
I've had no imaging performed
Silicon Valley MRI & CT
VRI (RadNet)
SimonMed
Sunnyvale Imaging
Rayus (Insight)
Precise Imaging
Other - please call our office to advise the location
GENERAL AREAS OF INTEREST FOR PAIN MANAGEMENT:
Medication
Physical therapy
Chiropractic
Acupuncture
Pain psychology
Pain injection or procedure
Regenerative treatment (stem cell or PRP injections)
Lifestyle IV drips (for cellular health, energy, wellness, anti-aging)
Weight management
Health coaching
Virtual reality (for chronic pain)
Brace support
IV ketamine (for chronic pain)
Surgery
Preferred Allied Pain & Spine locations for office visits - Please check all the locations that are best for scheduling:
*
San Jose (Blossom Hill)
Los Gatos
Morgan Hill
San Leandro
Mountain View
OTHER COMMENTS ABOUT PAIN, INJURY, TREATMENT COURSE, ETC:
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PAST MEDICAL HISTORY
*
None
[ADHD]
[Alcoholism]
[Allergic rhinitis]
[Anemia]
[Angina]
[Anxiety]
[Arthritis]
[Asthma]
[Atrial fibrillation]
[Basal cell cancer]
[Benign prostatic hypertrophy (BPH)]
[Bipolar disorder]
[Blood clot (DVT)]
[Bronchitis]
[Cardiac arrythmia]
[Cataracts]
[Carpal tunnel syndrome (RIGHT)]
[Carpal tunnel syndrome (LEFT)]
[Chronic joint pain]
[Chronic low back pain]
[Chronic neck pain]
[Chronic pain syndrome]
[Celiac disease]
[Cirrhosis]
[Colitis]
[Colon cancer]
[Complex regional pain syndrome (CRPS)]
[Constipation]
[COPD]
[Coronary artery disease (CAD)]
[Deep vein thrombosis (DVT)]
[Depression]
[Diabetes type I]
[Diabetes type II]
[Diverticulosis]
[Endometriosis]
[Erectile dysfunction]
[Fatty liver]
[Fibromyalgia]
[Gallbladder disease]
[Gallstones]
[Gastroesophageal reflux disease (GERD)]
[Gout]
[Head/brain injury]
[Heart attack (myocardial infarction)]
[Heart valve disorder]
[Hemorrhoids]
[Hepatitis B]
[Hepatitis C]
[High blood pressure (hypertension)]
[High cholesterol]
[HIV]
[Hyperlipidemia]
[Hyperthyroidism]
[Hypothyroidism]
[Insomnia]
[Irritable bowel syndrome (IBS)]
[Lupus]
[Lyme disease]
[Melanoma]
[Migraine headaches]
[Mitral valve prolapse]
[Multiple sclerosis]
[Murmur]
[Myofascial pain syndrome]
[Obesity]
[Osteoarthritis]
[Osteopenia]
[Osteoporosis]
[Overactive bladder]
[Peripheral neuropathy]
[Psoriasis]
[PTSD]
[Reflex sympathetic dystrophy (RSD)]
[Rheumatoid arthritis]
[Sciatica]
[Seizures]
[Sleep apnea]
[Spinal stenosis]
[Sports injuries]
[Squamous cell cancer]
[STDs]
[Stomach ulcer]
[Stroke]
[Thyroiditis]
[TMJ disorder]
[Vertigo]
Other
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PAST SURGICAL HISTORY
*
None
[Abdominal hernia repair]
[ADCF neck surgery]
[Aneurysm repair]
[Ankle/foot surgery (RIGHT)]
[Ankle/foot surgery (LEFT)]
[Appendix removal (appendectomy)]
[Bariatric surgery/gastric bypass]
[Bilateral tubal ligation]
[Bladder surgery]
[Bowel surgery]
[Breast biopsy]
[Breast implants]
[Breast reduction]
[Bunionectomy]
[C-Section]
[Carpal tunnel release surgery (RIGHT)]
[Carpal tunnel release surgery (LEFT)]
[Cataract surgery]
[Cervical/neck total disk replacement (TDR)]
[Cervical/neck fusion surgery]
[Coronary artery bypass grafting (CABG)]
[Deviated septum repair]
[Elbow surgery (RIGHT)]
[Elbow surgery (LEFT)]
[Fibroidectomy]
[Gallbladder removal (cholecystectomy)]
[Gastric bypass or stapling]
[Hemorrhoid surgery]
[Hip replacement (RIGHT)]
[Hip replacement (LEFT)]
[Hysterectomy]
[Inguinal hernia repair]
[Kidney stone removal]
[Knee ACL surgery (RIGHT)]
[Knee ACL surgery (LEFT)]
[Knee meniscus surgery (RIGHT)]
[Knee meniscus surgery (LEFT)]
[Knee replacement (RIGHT)]
[Knee replacement (LEFT)]
[Knee arthroscopy/scope (RIGHT)]
[Knee arthroscopy/scope (LEFT)]
[LASIK]
[Low back/lumbar disk surgery]
[Low back/lumbar fusion surgery]
[Low back/lumbar laminectomy or laminotomy]
[Open heart Surgery]
[Pacemaker]
[Prostate surgery]
[Rhinoplasty]
[Shoulder arthroscopy/scope (RIGHT)]
[Shoulder arthroscopy/scope (LEFT)]
[Shoulder labral repair (RIGHT)]
[Shoulder labral repair (LEFT)]
[Shoulder rotator cuff surgery (RIGHT)]
[Shoulder rotator cuff surgery (LEFT)]
[Sinus surgery]
[Skin cancer excision]
[TMJ surgery]
[Tonsillectomy]
[Trigger finger release (RIGHT hand)]
[Trigger finger release (LEFT hand)]
Other
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SOCIAL & WORK HISTORY
ALCOHOL USE
*
Do not drink
Drink occasionally or socially
Drink daily
History of alcoholism
TOBACCO USE
*
Never smoked
Former smoker
Current light/occasional smoker
Regular smoker
Other
DRUG USE
*
No history of illicit or recreational drug use
Past history of illicit or recreational drug use
Active use of illicit and/or recreational drugs
Other
HEALTH HABITS
No exercise
Occasional exercise
Regular exercise
Eat healthy/balanced diet
Unsafe sexual practices with exposure to STDs
MARITAL STATUS
Single
Married
Separated
Divorced
Widowed
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PREVIOUS WORK INJURY OR WORKER'S COMPENSATION CLAIM(S)
None
Yes, consisting of:
CURRENT OCCUPATIONAL STATUS
*
Working
Retired
Unemployed
Off work due to injury
Permanent disability
Other
CURRENT EMPLOYER
WORK POSITION/ JOB DUTIES
*
WORK RESTRICTIONS
*
None
Yes, consisting of:
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FAMILY HISTORY
No significant family medical history
Arthritis
Autoimmune disease
Cancer
Chronic kidney disease
Diabetes
Headache/ Migraine disorder
High blood pressure
Liver disease
Osteoporosis
Rheumatoid arthritis
Seizures
Stroke
Other
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REVIEW OF SYSTEMS
STATUS OF BODY SYSTEMS:
*
There are NO problems with GENERAL HEALTH, HEAD, EYES, EARS, NOSE, THROAT, HEART, LUNGS, DIGESTIVE SYSTEM, URINARY SYSTEM, SKIN, ALLERGIC/IMMUNOLOGIC SYSTEM, BLOOD, GLANDS, HORMONES, NEUROLOGIC SYSTEM, PSYCHOLOGICAL
There are problems in one or more system(s)of the body
GENERAL
*
No general issues
Normal with specific exceptions
GENERAL ABNORMALITIES
*
Fevers
Chills
Unexplained weight loss
Weight gain
Poor sleep
Other
HEAD/EYES/EARS/NOSE/ THROAT
*
Normal
Normal with specific exceptions
HEAD/EYES/EARS/NOSE/ THROAT ABNORMALITIES
*
Head trauma
Blurry vision
Light sensitivity
Ringing in ears
Sound sensitivity
Sinus pain
Runny nose
Difficulty swallowing
Hoarseness
Other
HEART
*
Normal
Normal with specific exceptions
HEART ABNORMALITIES
*
Chest pain
Irregular heart beat
Shortness of breath on exertion
Shortness of breath when lying down
Swelling in legs/feet
Other
LUNGS
*
Normal
Normal with specific exceptions
LUNG ABNORMALITIES
Difficulty breathing
Wheezing
Cough
Coughing up blood
Other
DIGESTIVE
*
Normal
Normal with specific exceptions
DIGESTIVE ABNORMALITIES
*
Abdominal pain
Nausea
Vomiting
Bright red blood per rectum
Black tarry stool
Constipation
Diarrhea
Other
URINARY
*
Normal
Normal with specific exception
URINARY ABNORMALITIES
*
Painful urination
Frequent urination
Blood in urine
Incontinence
Pain with sexual intercourse
Other
SKIN
*
Normal
Normal with specific exceptions
SKIN ABNORMALITIES
Rash
Itching
Change in hair or nails
Other
ALLERGIC/IMMUNOLOGIC
*
Normal
Normal with specific exceptions
ALLERGIC/IMMUNOLOGIC ABNORMALITIES
Hives
Seasonal/environmental allergies
Swollen lymph nodes
Other
BLOOD
*
Normal
Normal with specific exceptions
BLOOD ABNORMALITIES
Abnormal bruising
Frequent infections
Frequent or easy bleeding
Other
GLANDS/HORMONES
*
Normal
Normal with specific exceptions
GLAND/HORMONE ABNORMALITIES
Uncontrolled blood sugar
Excessive thirst
Excessive sweating
Uncontrolled thyroid disease
Other
NEUROLOGIC
*
Normal
Normal with specific exceptions
NEUROLOGIC ABNORMALITIES
Double vision
Facial asymmetry
Weakness
Hemisensory deficits
Vertigo
Dizziness
Poor balance
Frequent headaches
Other
PSYCHIATRIC
*
Normal
Normal with specific exceptions
PSYCHIATRIC ABNORMALITIES
Hallucinations
Mania
Suicidal/homicidal thoughts
Anxiety
Depression
Other
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BEHAVIORAL HEALTH and RISK ASSESSMENT
(These surveys are necessary in order to better analyze and manage your pain)
Date that below assessments were filled:
-
Month
-
Day
Year
Today's Date
Over the last 2 weeks, how often have the following depressive-type problems been present?
*
Not at all
Several days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things:
2. Feeling down, depressed, or hopeless:
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy:
5. Poor appetite or overeating:
6. Feeling bad about yourself-- or that you are a failure or have let yourself or family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed? Or the opposite-- being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself in some way
PHQ-9 Score (for office use):
Over the last 2 weeks, how often have the following anxiety-type problems been present?
*
Not at all
Several days
More than half the days
Nearly every day
1. Feeling nervous, anxious, or on edge:
2. Not being able to stop or control worrying:
3. Worrying too much about different things:
4. Trouble relaxing:
5. Being so restless that it is hard to sit still:
6. Becoming easily annoyed or irritable:
7. Feeling afraid as if something awful might happen:
GAD-7 Score (for office use):
Opioid Risk Tool (ORT) is a gender-specific assessment. Specification of gender for appropriate questionnaire:
*
Female
Male
Opioid Risk Tool (female):
*
YES
NO
1. Has there been family history of alcohol abuse?
2. Has there been family history of illegal drug use?
3. Has there been family history of recreational drug use?
4. Has there been personal history of alcohol abuse?
5. Has there been personal history of illegal drug abuse?
6. Has there been personal history of recreational drug abuse?
7. Aged between 16-45 years?
8. Has there been history of preadolescent sexual abuse?
9. Has there been a personal history of Attention Deficit Disorder (ADD or ADHD), bipolar or schizophrenia?
10. Has there been a personal history of depression?
Female ORT Score (for office use):
Opioid Risk Tool (male):
*
YES
NO
1. Has there been family history of alcohol abuse?
2. Has there been family history of illegal drug use?
3. Has there been family history of recreational drug use?
4. Has there been personal history of alcohol abuse?
5. Has there been personal history of illegal drug abuse?
6. Has there been personal history of recreational drug abuse?
7. Aged between 16-45 years?
8. Has there been history of preadolescent sexual abuse?
9. Has there been a personal history of Attention Deficit Disorder (ADD or ADHD), bipolar or schizophrenia?
10. Has there been a personal history of depression?
Male ORT Score (for office use):
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ACTIVITY of DAILY LIVING (ADLs)
Able to do the following independently?
YES
NO
Dress, including wearing of shoes:
Wash and dry self:
Take a bath:
Get on and off the toilet:
Cut food:
Lift a full cup to mouth:
Make a meal:
Write a note:
Type a message on a computer:
Use a telephone:
Work outdoors on flat ground:
Climb 1 flight of stairs:
Stand:
Sit:
Recline:
Rise from chair:
Run errands:
Light housework:
Feel what is touched:
Open car doors:
Turn faucets on and off:
Get in and out of bed:
Sleep:
Engage in sexual activity:
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ALLERGIES
PLEASE SPECIFY ANY MEDICATION ALLERGIES AND ASSOCIATED REACTIONS:
*
No known drug allergies
Yes— List:
MEDICATION LIST
Please note that we rely on accurate and complete medication information to provide safe and optimal care. Any medication misinformation can result in hospitalization or death.
Medication Name
Dosage
# Taken Daily
Ordering Doctor
1
2
3
4
5
6
7
8
9
10
11
12
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Signature
Submit
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