• New Patient Form - Pain Management

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Chief Complaint
  • Was the onset:
  • Is your problem:
  • Do you exercise:
  • Check all the words that describe your pain:
  • Check the activities that increase your pain:
  • Check the activities that improve your pain:
  • Please Rate Your Pain From 0 to 10 (0 is No Pain, 10 is Most Severe Pain Imaginable)
    Rows
  • Are you on any blood thinners?
  • Do you have a pacemaker?
  • Do you have a defibrillator?
  • Pain Treatment History - Interventions
    Rows
  • Have you had injections in the past? Trigger Point Injections, Nerve Ablations, Epidural Steroid Injections?
  • If Yes, which injections have you had and when did you have them?
    Rows
  • Any diagnostic testing for this condition?
  • Pain Treatment History - Past PAIN Medication history
    Rows
  • Have you ever taken medications differently than prescribed for you?
  • Do you have a history of drug addiction or dependence?
  • Do you have any known allergies to medication?
  • Allergies to medication
    Rows
  • Are you experiencing any of the following? Please mark all that apply

  • Past Medical History

  • Are you affected by any of the following?
  • Family History (check all that apply)
  • Marital Status:
  • Living Status:
  • Work Status:
  • Do you use tobacco?
  • Do you drink alcohol?
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Opioid Questionnaire

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Family History of Substance Abuse
    Rows
  • Personal History of Substance Abuse
    Rows
  • Are you between the ages of 16 and 45 years old?
  • History of preadolescent sexual abuse?
  • Personal History of Psychological Disease?
    Rows
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • New Patient Registration

    Demographics and Insurance
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Format: (000) 000-0000.
  • Need Interpreter?
  • Marital Status

  • The U.S Government Requires we ask the following two questions:
  • How do you identify your ethnicity?
  • How do you identify your race?
  • Employment Status
  • 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.
  • Sex
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Insurance

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Format: (000) 000-0000.
  • Do you have any other insurance?
  • Should be Empty: