New Patient Intake Form
Name
First Name
Middle Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your home address also your mailing address?
Yes
No, I would like my mail delivered to a different address
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Please provide the phone numbers in which you wish to be contacted:
*
I would like to provide a Cell Phone number
I would like to provide a Home Phone number
I would like to provide a Work Phone number
Cell Phone
Please enter a valid phone number.
Can we leave messages containing medical information on your CELL phone?
*
Yes
No
Home Phone
Please enter a valid phone number.
Can we leave messages containing medical information on your HOME phone?
*
Yes
No
Work Phone
Please enter a valid phone number.
Can we leave messages containing medical information on your WORK phone?
*
Yes
No
Date of Birth
 -
Month
 -
Day
Year
Date
Marital Status
Married
Unmarried
Other
Social Security Number
*
Employment Status
Employed
Unemployed, but seeking employement
Unemployed and retired
Unemployed due to disability
Please check all that apply:
*
I was hurt at my job and I am here under Workers Comp
I was hurt in a motor vehicle accident (or some other trauma) unrelated to my job
I was NOT hurt at my job or hurt in a motor vehicle accident or fall
If you know the name of your nurse case manager (NCM), please enter it here.
Is there an ongoing lawsuit or do you expect there to be a lawsuit?
*
Yes, a lawsuit is started or pending
No, a lawsuit is not pending or started
Other
What is the name of the attorney that you are working with?
What is the name of the attorneys office/practice that you are working with?
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Relationship to emergency contact
Spouse
Parent
Child
Sibling
Friend
Other
Can we discuss your health care information with this person?
*
Yes
No
Can we leave messages containing medical information on your Emergency Contact phone?
*
Yes
No
Emergency Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Advanced directive preferences. Do you have any of the following:
*
Living Will
Health Care Power of Attorney or Health care Proxy
I do not have an Advanced Directive.
What is the name of your preferred pharmacy?
*
What is the address and/or phone number of your preferred pharmacy?
*
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Who is your primary care physician?
What is the office name that your primary care physician works at?
Do you have a cardiologist (heart doctor)?
*
Yes
No
What is your cardiologists name?
What is the office name that your cardiologist works at?
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Insurance Information
Please take out your insurance card and look at it. Is your name spelled EXACTLY as you provided earlier on this form?
Yes, the name I provided earlier is EXACTLY the same as the name on my insurance card.
No, the name on my card is different.
I do not have insurance
Please enter the name exactly as it appears on your insurance card.
First Name
Middle Name
Last Name
We will now need to collect your insurance information. Please select how you would like to provide us this information:
I prefer to type it in manually
I am using a cell phone or tablet to complete this form and I would like to use the camera to take a picture of my insurance card(s).
I am using my home computer and I would like to scan and upload a picture of my insurance card(s)
Primary Insurance Name (the name of your insurance company)
*
Primary Insurance Number
*
Secondary Insurance Name (the name of your insurance company)
Secondary Insurance Number
Tertiary Insurance Name (the name of your insurance company)
Tertiary Insurance Number
Click below to take a photo of your Primary insurance card:
*
Click below to take a photo of your Secondary insurance card (you can skip this if it does not apply to you):
Click below to take a photo of your Tertiary insurance card (you can skip this if it does not apply to you):
How many files would you like to upload?
I have ONE file that contains all of my insurance information
I have TWO files that contain my insurance information
I have THREE files that contain my insurance information
Click here to select the file you would like to upload first:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Click here to select the file you would like to upload second:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Click here to select the file you would like to upload third:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Primary Concern
What part of your body is of GREATEST concern to you. We will call this your Primary Concern. This may be due to pain, numbness, weakness or other issues. You can only select one because this is your greatest area of concern. *After completing questions regarding your primary complaint, you will be asked questions regarding your secondary complaint.*
My head
My neck (cervical spine)
My neck and my right arm
My neck and my left arm
My neck and both of my arms
My left hand
My right hand
Both of my hands
My low back (lumbar spine)
My low back and right leg
My low back and left leg
My right foot
My left foot
Both of my feet
My mid-back (thoracic spine)
Other
Primary Concern: When did this pain start (approximately)?
Primary Concern: Since it started, has it gotten better, worse or stayed the same?
Primary Concern: How would you describe this pain? (select all that apply)
Deep throbbing ache
Dull ache
Burning sensation
Cold sensation
Cramping or spasm
Hot or inappropriately warm
Pressure
Sharp and shooting or a shock-like sensation
Numbness/tingling that is painful
Numbness/tingling that is NOT painful
Pinching
Primary Concern: "1" is little to no pain. "5" is moderate pain. "10" is the worst pain of your life.
Little to no pain
1
2
3
4
5
6
7
8
9
Worst pain of your life!
10
1 is Little to no pain, 10 is Worst pain of your life!
Primary Concern: How would you describe the frequency of this pain? (select all that apply)
Constant, all day and all night
Constant, but worse at night
Constant, but worse during the day
It mostly happens at night
It mostly happens during the day
It mostly happens when standing
It mostly happens when sitting
It mostly happens when walking
It is worse in the morning
It is worse in the evening
It suddenly comes and then immediately goes away
Other
Primary Concern: Which of the following have you done in the last 12 months?
Physical Therapy
Epidural steroid injections
Rhizotomy (aka RFA or Radio Frequency Ablation)
Chiropractor
Message
Accu-puncture
Tens unit
A brace
Other
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Secondary Concern
What part of your body is of SECONDARY concern to you. This may be due to pain, numbness, weakness or other issues. You can only select one because this is your SECONDARY area of concern.
My head
My neck (cervical spine)
My neck and my right arm
My neck and my left arm
My neck and both of my arms
My left hand
My right hand
Both of my hands
My low back (lumbar spine)
My low back and right leg
My low back and left leg
My right foot
My left foot
Both of my feet
My mid-back (thoracic spine)
Other
Secondary Concern: When did this pain start (approximately)?
Secondary Concern: Since it started, has it gotten better, worse or stayed the same?
Secondary Concern: How would you describe this pain? (select all that apply)
Deep throbbing ache
Dull ache
Burning sensation
Cold sensation
Cramping or spasm
Hot or inappropriately warm
Pressure
Sharp and shooting or a shock-like sensation
Numbness/tingling that is painful
Numbness/tingling that is NOT painful
Pinching
Other
Secondary Concern: "1" is little to no pain. "5" is moderate pain. "10" is the worst pain of your life.
Little to no pain
1
2
3
4
5
6
7
8
9
Worst pain of your life!
10
1 is Little to no pain, 10 is Worst pain of your life!
Secondary Concern: How would you describe the frequency of this pain? (select all that apply)
Constant, all day and all night
Constant, but worse at night
Constant, but worse during the day
It mostly happens at night
It mostly happens during the day
It mostly happens when standing
It mostly happens when sitting
It mostly happens when walking
It is worse in the morning
It is worse in the evening
It suddenly comes and then immediately goes away
Other
Secondary Concern: Which of the following have you done in the last 12 months?
Physical Therapy
Epidural steroid injections
Rhizotomy (aka RFA or Radio Frequency Ablation)
Chiropractor
Message
Accu-puncture
Tens unit
A brace
Other
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Are you using any of these assistive devices? (select all that apply)
A walking cane
A walker
A motorized scooter
Crutches
Do you use CURRENTLY use tobacco or nicotine products? (If you use more than one nicotine product, please select the one you use most)
Yes, I smoke cigarettes
Yes, I smoke cigars
Yes, I vape
Yes, I use chewing tobacco
No, I do not currently use tobacco or nicotine products.
Regarding cigarettes, how many packs per day and for how many years?
Regarding cigar, how many cigars per day and for how many years?
Regarding vaping, how many vaping events per day and for how many years?
Regarding chewing tobacco, how many dips per day and for how many years?
Have you PREVIOUSLY used tobacco or nicotine products, but no longer use them?
Yes, I used to smoke cigarettes
Yes, I used to smoke cigars
Yes, I used to vape
Yes, I used to dip (chewing tobacco)
No, I have never used tobacco or nicotine products.
What year did you stop using it?
Regarding Illicit (illegal) drug use:
I have never used illicit or illegal drugs.
When I was much younger I tried illicit or illegal drugs, but I no longer use them.
I am currently or have recently used illicit or illegal drugs.
Please tell us what illicit or illegal drugs you have recently used:
Have you ever abused a prescription narcotic or any other prescription medication?
Yes
No
What medication(s) have you abused?
Spine Surgery History:
I have had surgery on my neck (cervical spine)
I have had surgery on my mid-back (thoracic spine)
I have had surgery on my low back (lumbar spine)
Do you have a pain management physician? This would be there person who did injections or prescribes pain medicines.
Pain Specialists of Charleston (Dr. Tavel, Dr. Drakeley),
Carolina Pain Physicians (Dr. Owens)
Trident Pain Center (Dr. Nolan, Dr. Maggio, Dr. Thatcher, Dr. Antonovich)
Lowcountry Orthopedics (Dr. Merrell, Dr. Patel)
DeNovo Pain (Dr. Arcella)
Pain Institute of Charleston (Dr. Gardner)
Roper Pain Management (Dr. Randall)
Coastal Pain and Spine (Dr. Hill, Dr. Kinch)
Signe Spine (Dr. Nemeth)
Southern Grace (Dr. Richardson)
Southern Coast Pain Specialists (Dr. Schuyler)
Other
Have you had an MRI or Cat Scan of the SPINE done in the last 12 months? (hint: an MRI is a long tube that you lay in for about 20 minutes. You are usually given headphones because the machine is loud. A Cat Scan, or CT Scan, is a short tube and the scan only takes 5 minutes or less.)
Yes, I have done an MRI within the last 12 months
Yes, I have done a CT within the last 12 months
No, I have not done an MRI or CT within the last 12 months
I am not sure
Was your recent MRI or CT scan done at one of the following facilities? (select all that apply)
Medical University of South Carolina (MUSC)
Trident, Summerville or Colleton Medical Center
Roper (including St. Francis, Downtown, Berkeley and Mt Pleasant)
East Cooper Medical Center (ECMC)
Beaufort Memorial Hospital (BMH)
Imaging Specialists
Tricounty Radiology
Axis 3T MRI
American Health Imaging
Palmetto Primary Care Diagnostic Imaging Center
MRI of Charleston (aka Pain Specialists of Charleston)
Lowcountry Orthopedics
Other
Please select any blood thinners that you are taking?
*
I am NOT taking any blood thinners
Aspirin
BC Powder
Goody Powder
Plavix
Effient
Brillinta
Aggrenox
Teclid
Coumadin or Warfarin
Eliquis or Pradaxa or Xerelto
Lovenox
Fish oil or Cod liver oil
Other
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Medications
Are you taking any medications including vitamins and/or suppliments?
Yes
No
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Is this a complete list of your medication or do you have more to enter?
I have entered all of my medications
I have more to enter
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
Medication name, dose and frequency
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Allergies
Do you have allergies to any medication, food or any topical products?
Yes
No
Allergy #1: Please tell us what you are allergic to and what is your reaction?
Allergy #2: Please tell us what you are allergic to and what is your reaction?
Allergy #3: Please tell us what you are allergic to and what is your reaction?
Allergy #4: Please tell us what you are allergic to and what is your reaction?
Allergy #5: Please tell us what you are allergic to and what is your reaction?
Allergy #6: Please tell us what you are allergic to and what is your reaction?
Allergy #7: Please tell us what you are allergic to and what is your reaction?
Allergy #8: Please tell us what you are allergic to and what is your reaction?
Allergy #9: Please tell us what you are allergic to and what is your reaction?
Allergy #10: Please tell us what you are allergic to and what is your reaction?
Is this a complete list of your allergies or do you have more to enter?
I have entered all of my allergies
I have more to enter
Allergy #11: Please tell us what you are allergic to and what is your reaction?
Allergy #12: Please tell us what you are allergic to and what is your reaction?
Allergy #13: Please tell us what you are allergic to and what is your reaction?
Allergy #14: Please tell us what you are allergic to and what is your reaction?
Allergy #15: Please tell us what you are allergic to and what is your reaction?
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Medical and Surgical History
Please mark off any of the following conditions that you have been diagnosed with or have been treated for.
ENT
Glaucoma
Vertigo
Hearing Problems
Frequent Nose Bleeding
Other
Heart and Vascular Conditions
Heart Attack
Cardiac Stents
Coronary Artery Disease
Peripheral Vascular Disease
Stroke or TIA ("mini-stroke")
Type option 4
Other
Hematologic Conditions
Anemia (low red blood cell count)
Thrombocytopenia (low platelet count)
Leukemia
Other
Respiratory Conditions
COPD or Emphysema
Sleep Apnea
Pneumonia
Bronchitis
Other
Musculoskeletal and Rheumatologic
Osteoarthritis
Osteoporosis
Osteopenia (early stage osteoporosis)
Rheumatoid Arthritis
Ankylosing Spondylitis
Fibromyalgia
Carpal Tunnel Syndrome
Other
Gastrointestinal
GERD (Acid Reflux)
Gastrointestinal Bleeding
Stomach Ulcers
Irritable Bowel Disease
Inflammatory Bowel Disease
Crohns Disease
Bowel Incontinence
Other
Urological
Chronic Kidney Disease
Kidney Stones
Urinary Incontinence
Dialysis
Other
Neurological
Multiple Sclerosis
Peripheral neuropathy
Seizures
Poor balance
Concussion
Closed Head Injury
Migraines
Polio
Guillain Barre Syndrome
Other
Psychological
Depression
Anxiety
Schizophrenia
Bipolar Disorder
ADD or ADHD
PTSD
Other
Endocrinologic
Diabetes, type 1 (usually juvenile onset)
Diabetes, type 2 (usually adult onset)
Hyperthyroidism
Hypothyroidism
Other
If you have ever had a cancer diagnosis, treated or untreated, please list it here:
Please list any other medical condition that you have been diagnosed with, treated or untreated:
Have you had surgery before?
*
Yes
No
Please list any surgeries you have had. List the name of the procedure and the approximate year it was done.
Have you been hospitalized for any reason other than for scheduled surgery?
*
Yes
No
What was/were your unplanned hospitalization(s) for?
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Family History
Please select any of these common medical conditions that your FATHER has or had:
My father is alive
My father is deceased
Diabetes
Hypertension
Heart or Vascular disease
Mental Illness
Stroke
Cancer, Leukemia
Alcohol Abuse
Illegal Drug Abuse
Gambling Addiction
Please select any of these common medical conditions that your MOTHER has or had:
My mother is alive
My mother is diseased
Diabetes
Hypertension
Heart or Vascular disease
Mental Illness
Stroke
Cancer, Leukemia
Alcohol Abuse
Illegal Drug Abuse
Gambling Addiction
Please select any of these common medical conditions that your SIBLINGS has or had:
Diabetes
Hypertension
Heart or Vascular disease
Mental Illness
Stroke
Cancer, Leukemia
Alcohol Abuse
Illegal Drug Abuse
Gambling Addiction
Please select any of these common medical conditions that your CHILDREN has or had:
Diabetes
Hypertension
Heart or Vascular disease
Mental Illness
Stroke
Cancer, Leukemia
Alcohol Abuse
Illegal Drug Abuse
Gambling Addiction
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Review of Systems
Please check off any symptoms that you are CURRENTLY experiencing.
General / Constitutional Symptoms
Fever
Chills
Sweats
Weakness
Fatigue or Malaise
Decreased Activity
Unexplained weight gain
Unexplained weight loss
Low sex drive
Difficulty sleeping
Other
Allergy / Immunology
Seasonal allergies
Hay fever
Itching
Exposure to HIV
Other
Ophthalmologic
Blurriness of vision
Double Vision
Visual Disturbance
Eye pain
Other
ENT
Hearing problems
Ear pain
Sinus problems
Sore throat
Nose bleeding
Tinnitis or ringing in the ears
Other
Endocrine
Excessive Thirst
Excessive Urination
Heat intolerance
Cold Intolerance
A sudden increase in hair loss
Other
Gastrointestinal
Nausea
Vomiting
Diarrhea
Constipation
Heartburn
Abdominal pain
Other
Skin
Rash
Itching
New lesions
Unexpected bruising
Other
Neurologic
Poor balance and/or coordination
Confusion
Numbness
Tingling
Dizziness or Vertigo
Headaches
Memory loss
Seizures
Tremors
Other
Psychiatric
Feeling anxious
Feeling depressed
Hallucinations
Heightened stress
Other
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All done!
If there is any other medical information you would like to share with us, please enter it here:
If there is any other feedback you would like to give us, please enter it here:
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