New Patient Form - Pain Management
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Today's Date
-
Month
-
Day
Year
Date
Primary Doctor
Referring Doctor
Chief Complaint
Neck Pain
Arm Pain
Back Pain
Leg Pain
Other
How long has your problem been present?
Has it worsened recently?
What started your problem?
Was the onset:
Gradual
Sudden
Is your problem:
Getting worse
Getting better
About the same
Do you exercise:
Daily
Regularly
Weekly
Occasionally
Never
Do you use an assistive device?
If yes, list type (cane, walker, wheelchair, etc)
Check all the words that describe your pain:
Burning
Stabbing/Sharp
Pins/Needles
Ache/Dull
Numbness
Describe your pain and location
Back
Next
Check the activities that increase your pain:
Gripping
Arm Raising
Sitting
Standing
Walking
Lying Down
Turning Head
Driving
Climbing Stairs
Lifting
Bending
Twisting
Coughing
Going down stairs
Other
Check the activities that improve your pain:
Lying Down
Walking
Sitting
Heat
Ice
Standing
Bending
Other
Please Rate Your Pain From 0 to 10 (0 is No Pain, 10 is Most Severe Pain Imaginable)
Pain Today
Minimum Pain
Maximum Pain
Average Daily Pain
Rating
What number best describes your pain on average in the past week:
0 = No Pain, 5 = Moderate, 10 = Severe
What number best describes how, during the past week pain has interfered with your enjoyment of life:
0 = Does not interfere, 4 = Slight/Mild 6 = Moderate, 10 = Completely interferes
How much has your activities of daily living improved since your last visit:
0 = None, 2/3 = Mild 5/6 = Moderate, 10 = Very Significant
Please list all current PAIN medications (prescription and non-prescription)
Include Name, dose or strength, and how often taken
Please list all current non-pain medications (prescription and non-prescription)
Include Name, dose or strength, and how often taken and include any vitamins or nutritional supplements
Are you on any blood thinners?
Yes
No
If yes, which one?
Do you have a pacemaker?
Yes
No
Do you have a defibrillator?
Yes
No
Pain Treatment History - Interventions
When (Date/Years)
% Helped
Physical Therapy
Manipulation/Massage
Have you had injections in the past? Trigger Point Injections, Nerve Ablations, Epidural Steroid Injections?
Yes
No
If Yes, which injections have you had and when did you have them?
When (Date/Years)
% Helped
Type of Injection
Injections
Injections
Injections
Any diagnostic testing for this condition?
None
Plain X-rays
MRI Scan
CT Scan
Myelogram
Nerve Tests (EMG, NCS)
Pain Treatment History - Past PAIN Medication history
Name
Did it help?
Any side effects?
Pain Medication
Pain Medication
Pain Medication
Have you ever taken medications differently than prescribed for you?
Yes
No
If yes, please explain?
Do you have a history of drug addiction or dependence?
Yes
No
If yes, explain treatment?
Do you have any known allergies to medication?
Yes
No
Allergies to medication
Medication
Describe Reaction
Allergy
Allergy
Allergy
Are you experiencing any of the following? Please mark all that apply
Anxiety
Double Vision
Blurry Vision
Bowel Incontinence
Chest Pain
Constipation
Cough
Depression
Difficulty Breathing
Dizziness
Drowsiness
Fatigue
Fever
Headache
Hearing Changes
Heartburn
Insomnia
Memory Loss
Mood Swings
Nausea
Rash
Seizure
Shortness of Breath
Swelling
Urinary Hesitance
Urinary Incontinence
Urinary Urgency
Unexplained weight loss
Vomiting
Wounds or Ulcers
Past Medical History
Are you affected by any of the following?
Abnormal Heart Rhythm
Glaucoma
Liver Disease
Alcoholism
Gout
Nausea
Anemia
Gynecological Issue
Osteoporosis
Ankylosing Spondylitis
Heart Attack
Peripheral Neuropathy
Anxiety
Heart Failure
Peripheral Vascular Disease
Asthma
Hepatitis
Rheumatoid Arthritis
Bleeding Disorders
High Cholesterol
Seizures
Blood Clots
HIV/AIDS
Sleep Apnea
Cancer
Irritable Bowel Syndrome
Stomach Ulcers
Depression
Kidney Problem
Stroke
Thyroid Disease
Diabetes
Fibromyalgia
Lung Disease
Other
Surgical History:
Family History (check all that apply)
Unknown
Diabetes
Heart Disease
Obesity
Stroke
Cancer
Spinal Disorder
Vascular Disease
Marital Status:
Single
Married
Cohabitating
Widowed
Divorced
Living Status:
Alone
Spouse
Parents
Roommate
Assisted Living
Work Status:
Employed
Unemployed
Disabled
Retired
If Employed, Occupation:
Do you use tobacco?
No
Yes
If yes, how much and for how long?
Do you drink alcohol?
No
1-2 drinks/week
3-4 drinks/week
5 or more drinks a week
No longer drink
Signature
Date
-
Month
-
Day
Year
Date
Back
Next
Opioid Questionnaire
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Family History of Substance Abuse
Yes
No
Alcohol
Illegal Drugs
Prescription Drugs
Personal History of Substance Abuse
Yes
No
Alcohol
Illegal Drugs
Prescription Drugs
Are you between the ages of 16 and 45 years old?
Yes
No
History of preadolescent sexual abuse?
Yes
No
Personal History of Psychological Disease?
Yes
No
Attention Deficit Disorder
Obsessive-Compulsive Disorder
Bipolar
Schizophrenia
Depression
Signature
Date
-
Month
-
Day
Year
Date
Back
Next
New Patient Registration
Demographics and Insurance
Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
123-45-6789
Sex
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Primary Language
Need Interpreter?
Yes
No
Marital Status
Divorced
Legally Separated
Married
Significant Other
Single
Widowed
Religious Preference
Put Prefer not to disclose if you choose not to disclose
The U.S Government Requires we ask the following two questions:
How do you identify your ethnicity?
Hispanic or Latino
Not Hispanic or Latino
Prefer not to answer
How do you identify your race?
American Indian Or Alaska Native
Native Hawaiian
White or Caucasian
Black or African American
Other Pacific Islander
Asian
Prefer not to answer
Who is your primary care physician?
Name of the primary care practice
Employment Status
Full-time
Part-time
Retired
Disabled
Student
Unemployed
Employer Name
Number of Employees at Company
Emergency Contact Name
First Name
Last Name
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to you
Phone Number
Please enter a valid phone number.
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
Sex
Male
Female
Social Security Number
123-45-6789
Date of Birth
-
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.
Insurance
Medical Insurance Company Name
Member/Subscriber Identification #
Group #
Medical Insurance Company Address
Relationship of insured to self
Please Select
Self
Parent
Spouse
Other
Subscriber's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Sex
Male
Female
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have any other insurance?
Yes
No
Submit
Submit
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