Adult New Patient Form
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Birthday
*
-
Month
-
Day
Year
Date
Height
*
Feet
Inches
Weight
*
Referring Physician Name
First Name
Last Name
Referring Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Internist or Family Physician Name
First Name
Last Name
Internist or Family Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Name
Pharmacy City
Pharmacy Cross Streets
Part A. General Complaint Information
1. Chief Complaint (check all that apply):
Spinal Deformity (Scoliosis, Kyphosis, Flatback Syndrome, etc.)
Neck Pain
Arm Pain
Arm Numbness
Arm Weakness
Back Pain
Leg Pain
Leg Numbness
Leg Weakness
2. Your Age
Years
Months
3. Your Gender
Male
Female
4. How long has the pain (or your problem) been present?
5. Has your problem worsened recently?
Yes
No
5.a. If yes, how recently?
6. What started the pain or problem?
Part B. Neck or Arm Complaints (skip if no neck or arm complaints)
1. What % of your complaint is in the back and what % is leg or buttock? (check appropriate box)
All Arm
Arm 75%, Neck 25%
Arm 50%, Neck 50%
Arm 25%, Neck 75%
All Neck
2. Symptoms are on the following side:
100% Left
75% Left, 25% Right
50% Left, 50% Right
25% Left, 75% Right
100% Right
3. Please select where you are experiencing arm and hand pain.
Rows
No Pain
Upper Back
Shoulder
Upper Arm
Forearm
Hand/Finger
Right
Leg
3.a. Raising the arm:
Improves the pain
Worsens the pain
Does not affect the pain
3.b. Moving the neck:
Improves the pain
Worsens the pain
Does not affect the pain
4. Please select where you are experiencing arm or hand weakness.
Rows
No Weakness
Shoulder
Upper Arm
Forearm
Hand/Finger
Right
Left
5. Please select where you are experiencing are or hand numbness.
Rows
No Numbness
Upper Arm
Forearm
Thumb
Index Finger
Long Finger
Ring Finger
Small Finger
Right
Left
6. Do you have difficulty picking up small objects like coins or buttoning buttons?
Yes
No
7. Do you have a problem with balance or tripping frequently?
Yes
No
8. Do you have frequent or occasional headaches in the back of the head?
Yes, frequently
Yes, occasionally
No
9. Lying down:
Eases the pain
Does not ease the pain
Sometimes eases the pain
10. Bending forward:
Increases the pain
Decreases the pain
Doesn't affect the pain
Part C. Back or Leg Complaints (skip if no back or leg complaints)
1. What % of your complaint is in the back and what % is leg or buttock? (check appropriate box)
All Leg
Leg 75%, Back 25%
Leg 50%, Back 50%
Leg 25%, Back 75%
All Back
2. Symptoms are on the following side:
100% Left
75% Left, 25% Right
50% Left, 50% Right
25% Left, 75% Right
100% Right
3. Please select where you are experiencing leg pain.
Rows
No Pain
Buttock
Thigh-Front
Thigh-Back
Calf
Foot
Right
Leg
4. Please select where you are experiencing leg weakness.
Rows
No Weakness
Thigh
Calf
Foot
Ankle
Big Toe
Right
Left
5. Please select where you are experiencing leg numbness.
Rows
No Numbness
Thigh
Calf
Foot
Right
Left
6. The worst position is:
Sitting
Standing
Walking
7. How many minutes can you stand in one place without pain?
0-10
15-30
30-60
60+
8. How many minutes can you walk without pain?
0-10
15-30
30-60
60+
9. Lying down:
Eases the pain
Does not ease the pain
Sometimes eases the pain
10. Bending forward:
Increases the pain
Decreases the pain
Doesn't affect the pain
Part D. Spinal Deformity or Curvature (please skip if not applicable)
1. How was your spinal deformity discovered?
2. Your present curve measurement(s):
3. Reason for seeking treatment now:
Progressive deformity
Pain
Can't stand straight
I don't like the appearance of my back/waistline
Other
Part E. Required Responses
1. What does coughing or sneezing do to your symptoms?
*
Increases
Sometimes increases
Does not increase
2. Have you experienced loss of bowel or bladder control?
*
Yes
No
3. Have you missed any work because of this problem, if so, how much?
*
4.a. Neck treatments have included (check all that apply):
No medicines, therapy, manipulations, injections, or braces
Physical therapy, exercise
Massage and ultrasound
Traction
Manipulation
Tens Unit
Shoulder Injections
Braces
Anti-Inflammatory medications
Narcotic medication
Epidural Steroid injections
Trigger point injections
Surgery
4.b. Back treatments have included (check all that apply):
No medicines, therapy, manipulations, injections, or braces
Physical therapy, exercise
Massage and ultrasound
Traction
Manipulation
Tens Unit
Shoulder Injections
Braces
Anti-Inflammatory medications
Narcotic medication
Epidural Steroid injections
Trigger point injections
Surgery
5. Please list any doctors you've seen about this problem, including their specialty if known, the city they practice in, and the treatments they performed.
*
6. Please list all imaging studies (MRI, CT, DEXA scan, bone scan, etc.) you've received for this problem.
*
Part F. Medications
1. Please list all medications you take (include over-the-counter medications, aspirin, supplements)
2. Please list all known ALLERGIES to medications and adverse reactions you have experienced (rash, upset stomach, swelling, etc.)
Part H. Medical History
1. Medical History (check all that apply):
None
Heart attack
Heart failure
High blood pressure
Osteoarthritis
Rheumatoid Arthritis
Ankylosing spondylitis
Gout
Osteoporosis
Diabetes
Stroke
Seizures
Mental illness
Kidney stones
Kidney failure
Cancer
Alcoholism
Lung disease
HIV
AIDS
Tuberculosis
Asthma
Blood clot in leg
Blood clot in lung
Stomach Ulcers
Liver trouble
Hepatitis
Thyroid trouble
Bleeding disorders
Anemia
Serious injury
Fibromyalgia
Other
Part I. Surgical History
1. Please list all previous surgeries you've received, detailing the procedures, surgeon, and date.
Part J. Family History
1. Please select all that apply:
None
Stroke
Heart trouble
High blood pressure
Diabetes
Arthritis
Gout
Seizures
Spine problems
Mental illness
Kidney trouble or stones
Cancer
Bleeding disorders
Alcoholism
Osteoporosis
Other
Part K. Social History
1.a. Work Status
Homemaker
Retired
Disabled
On leave
Unemployed
Work full time
Work part time
1.b Occupation:
2. Marital status:
Married
Single
Cohabitating
Widowed
Divorced
3. Number of living children:
4. Please list any sports you participate in.
5. Please describe your tobacco use (cigars, cigarettes, quit after how many years of smoking, etc.).
7. Please describe your alcohol consumption (never, rarely, frequently, recovering alcoholic, etc.).
8. Drug overuse/abuse:
Never
Currently
In the past
9. Because of this spine problem, I have filed or plan to file:
A lawsuit
A Worker's Compensation claim
Neither a lawsuit or Worker's Compensation claim
Part L. Review of Systems
1. Please select any condition, symptom, or event that applies.
None
Reading glasses
Change of vision
Loss of hearing
Ear pain
Hoarseness
Nosebleeds
Difficulty swallowing
Morning cough
Shortness of breath
Fever or chills
Heart or chest pain
Abnormal heartbeat
Swollen ankles
Calf cramps w/ walking
Poor appetite
Toothache
Gum trouble
Nausea or vomiting
Stomach pain
Ulcers
Frequent belching
Frequent diarrhea
Frequent constipation
Hemorrhoids
Frequent urination
Burning urination
Difficulty starting urination
Get up more than once every night to urinate
Frequent headaches
Blackouts
Seizures
Frequent rash
Hot or cold spells
Recent weight change
Nervous exhaustion
Irregular periods
Vaginal discharge
Frequent spotting
Other
2. In general, are your symptoms getting better or worse?
Much better
Somewhat better
Staying about the same
Somewhat worse
Much worse
3. If you had to spend the rest of your life with the symptoms you have right now, would you be:
Very dissastisfied
Somewhat dissatisfied
Neutral
Somewhat satisfied
Very satisfied
Signature
Date
-
Month
-
Day
Year
Date
Part M. Areas Affected
1. Aching - please describe where on your body you feel aching.
2. Numbness - please describe where on your body you feel numbness.
3. Pins & Needles - please describe where on your body you feel pins and needles.
4. Burning - please describe where on your body you feel burning.
5. Stabbing - please describe where on your body you feel stabbing.
Part N. Demographics & Insurance
Name
First Name
Middle Name
Last Name
SSN
Date of Birth
-
Month
-
Day
Year
Date
Sex:
Please Select
Male
Female
Patient Street Address
Patient Street Address Line 2
City
State
ZIP
Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Primary Language
Need Interpreter?
Yes
No
Marital Status
Divorced
Legally Separated
Married
Other
Significant Other
Single
Widowed
Religious Preference
How Do You Identify Your Race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian
Other Pacific Islander
White or Caucasian
I Prefer Not to Answer
How Do You Identify Your Ethnicity?
Hispanic or Latino
Not Hispanic or Latino
Prefer Not to Answer
Primary Care Physician
Primary Care Practice
Employment Status
Full Time
Part Time
Retired
Disabled
Student
Unemployed
Employer Name
Number of Employees at Company
Emergency Contact Name
Emergency Contact Address
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Guarantor
Who is the guarantor of your account? Who is financially responsible for any amount not paid by the insurance company? Please write "self" if you are financially responsible.
Name
First Name
Middle Name
Last Name
SSN
Date
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance
Medical Insurance Company Name
Member/Subscriber Identification #
Group #
Medical Insurance Company Address
Relationship of the Insurance Subscriber to the Patient
Self
Parent
Spouse
Other
Subscriber Name
First Name
Middle Name
Last Name
Subscriber SSN
Subscriber Birth Date
-
Month
-
Day
Year
Date
Subscriber Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any additional insurance? Please present all insurance cards upon arrival.
Yes
No
Continue
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