New Patient Packet 1.0

1
Linked from Schedule Appointment Form
2
Please arrive 30 minutes prior to your appointment.

If you need to reschedule please do so within 24 hours of a scheduled appointment.

Please review the following information carefully:

You will need to bring or complete the following:

A COMPLETED NEW PATIENT PACKET

ALL IMAGING STUDIES(XRAY,MRI,CT)-THE ACTUAL DISC & REPORT

INSURANCE CARD

ATTORNEY INFORMATION

DRIVER’S LICENSE OR PICTURE IDENTIFICATION

ALL WRITTEN RECORDS REGARDING SPINE TREATMENT WITHIN THE PAST YEAR

Please contact us at 843-849-1551 if you have any additional questions.
3
I attest that I am the Patient or authorized by the Patient to answer the following questions.* This field is required.
YESNO
4
How were you referred to Southeastern Spine?* This field is required.
TV commercial
Physician referral
Internet
Word of mouth
Family or friend
Attorney
Other
5
Referring Physician* This field is required.
6
Patient Name* This field is required.
First Name
Middle Name
Last Name
7
Patient Date of Birth* This field is required.
Date
Month
Day
Year
8
Patient Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Patient Email* This field is required.
example@example.com
10
Patient Mobile Phone* This field is required.We require your mobile phone for reminders and identification purposes. We will not share the number.
Please enter a valid phone number.
11
Patient Secondary PhoneThis could be your home phone or other phone number to help us reach you. This field is not required.
Please enter a valid phone number.
12
Appointment Reminder Method
Text
Phone call
13
Who is your Primary Care Physician?
14
Race* This field is required.
Decline
Hispanic or Latino
White - not Hispanic or Latino
American Indian
Native Alaskan
Black or African American
Asian
Native Hawaiian
Pacific Islander
15
Primary Language* This field is required.
16
Do you have current Health Insurance?* This field is required.
YESNO
17
Primary Insurance Company Name* This field is required.
18
Insured Name* This field is required.This could be you, a spouse, or a parent. If it is you, you can enter "me".
19
Insured Date of Birth* This field is required.
Date
Month
Day
Year
20
Insured Member ID* This field is required.
21
Is there a Secondary Insurance?* This field is required.This is also known as supplemental insurance.
YESNO
22
Secondary Insurance Company Name* This field is required.
23
Secondary Insured Name* This field is required.This could be you, a spouse, or a parent. If it is you, you can enter "me".
24
Secondary Insured Date of Birth* This field is required.
Date
Month
Day
Year
25
Secondary Insurance Member ID* This field is required.
26
Are you requesting health care services related to an accident, injury, or Workmans Comp?* This field is required.If you are requesting health care services related to an accident, your health insurance company may not accept responsibility until you notify them of the accident details.
YESNO
27
Type of accident or injury:* This field is required.
Workers Comp
Motor vehicle
Other
28
Date of Injury* This field is required.
Date
Month
Day
Year
29
Briefly Describe the Injury* This field is required.
30
Location of the accident or injury:* This field is required.
31
Were you taken to a hospital?* This field is required.
YESNO
32
Were you admitted to the hospital?* This field is required.Did you spend at least one night in the hospital?
YESNO
33
Is another person responsible for the motor vehicle accident?
YESNO
34
Please pick the appropriate choice:
I was driving
I was a passenger
35
Briefly describe the accident:* This field is required.
36
Do you have a copy of the accident report?* This field is required.
YESNO
37
Name of the person causing the accident:
38
Address of the person causing the accident:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
39
Phone number of the person causing the accident
Please enter a valid phone number.
40
Name of the Auto Insurance Company of the person causing the accident:
41
Address of the Auto Insurance Company of the person causing the accident:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
42
Phone Number of the Auto Insurance Company for the person causing the accident:
Please enter a valid phone number.
43
Name of your Auto Insurance Company:* This field is required.
44
Policy Number of your Auto Insurance Company:* This field is required.
45
Address of your Auto Insurance Company* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
46
Phone Number of your Auto Insurance Company* This field is required.
Please enter a valid phone number.
47
Do you have an attorney representing you for this?* This field is required.
YESNO
48
Attorney Name* This field is required.
49
Attorney Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
50
Attorney Phone Number* This field is required.
Please enter a valid phone number.
51
Please read carefully and choose your preference:
I hereby request that the Southeastern Spine Institute pursue payment of my medical bills from the auto or accident insurance of the person responsible for the accident instead of billing my health insurance.
I hereby request that the Southeastern Spine Institute bill my Health Insurance. I acknowledge that in this case, I am responsible for remitting payment of all insurance deductibles and co-payments at the time of service or before service is provided.
52
Have you filed a Work Comp claim yet?* This field is required.
YESNO
53
Has the claim been accepted?* This field is required.
YESNO
54
Workmans Comp Insurance Carrier:
55
Name of your Case Manager or Adjuster:
56
Workmans Comp Claim Number:
57
Are you having pain?* This field is required.
YESNO
58
Intensity* This field is required.
I have no pain at the moment
The pain is very mild at the moment
The pain is moderate at the moment
The pain is fairly severe at the moment
The pain is very severe at the moment
The pain is the worst imaginable at the moment
59
Personal Care (eg. Washing or Dressing)* This field is required.
I can look after myself normally without causing extra pain
I can look after myself normally but it causes extra pain
It is painful to look after myself and I am slow and careful
I need some help but manage most of my personal care
I need help every day in most aspects of self-care
I do not get dressed, I wash with difficulty and stay in bed
60
Lifting* This field is required.
I can lift heavy weights without extra pain
I can lift heavy weights but it gives extra pain
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently placed eg. on a table
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned
I can lift very light weights
I cannot lift or carry anything at all
61
Walking* This field is required.
Pain does not prevent me from walking any distance
Pain prevents me from walking more than 2 miles
Pain prevents me from walking more than 1 mile
Pain prevents me from walking more than 500 yards
I can only walk using a stick or crutches
I am in bed most of the time
62
Sitting* This field is required.
I can sit in any chair as long as I like
I can only sit in my favorite chair as long as I like
Pain prevents me sitting more than one hour
Pain prevents me from sitting more than 30 minutes
Pain prevents me from sitting more than 10 minutes
Pain prevents me from sitting at all
63
Standing* This field is required.
I can stand as long as I want without extra pain
I can stand as long as I want but it gives me extra pain
Pain prevents me from standing for more than 1 hour
Pain prevents me from standing for more than 3 minutes
Pain prevents me from standing for more than 10 minutes
Pain prevents me from standing at all
64
Sleeping* This field is required.
My sleep is not disturbed by pain
My sleep is occasionally disturbed by pain
Because of pain I have less than 6 hours sleep
Because of pain I have less than 4 hours sleep
Because of pain I have less than 2 hours sleep
Pain prevents me from sleeping at all
65
Sex Life* This field is required.
Not applicable
My sex life is normal and causes no extra pain
My sex life is normal but causes some extra pain
My sex life is nearly normal but is very painful
My sex life is nearly absent because of pain
Pain prevents any sex life at all
66
Social Life* This field is required.
My social life is normal and gives me no extra pain
My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from limiting my more energetic interests eg, sports
Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home
I have no social life because of pain
67
Traveling* This field is required.
I can travel anywhere without pain
I can travel anywhere but it gives me extra pain
Pain is bad but I manage journeys over two hours
Pain restricts me to journeys of less than one hour
Pain restricts me to short necessary journeys under 30 minutes
Pain prevents me from traveling except to receive treatment
68
What is your usual level of pain on a scale of 0-10* This field is required.
69
Draw on Body
70
Describe your symptoms* This field is required.Give the important details
71
How long have the symptoms been present?* This field is required.Chose the best answer
Less than 1 week
1 week
2 weeks
3 weeks
1 month
Several months
6 months
Less than 1 year
1 year
More than 1 year
Many years
72
What other Physicians or Providers have treated you for this so far?* This field is required.
73
I'm having:* This field is required.Pick the best option
100% back pain and 0% leg pain
75% back pain and 25% leg pain
50% back pain and 50% leg pain
25% back pain and 75% leg pain
0% back pain and 100% leg pain
None of these apply to me
74
I'm having:* This field is required.Pick the best option
100% neck pain and 0% arm pain
75% neck pain and 25% arm pain
50% neck pain and 50% arm pain
25% neck pain and 75% arm pain
0% neck pain and 100% arm pain
None of these apply to me
75
What makes your pain better?* This field is required.
76
What makes your pain worse?* This field is required.
77
Have you had any of these tests in the last year?* This field is required.Select all that apply
MRI of the spine
CT Scan of the spine
Myelogram
X-ray of the spine
EMG
Bone Density Study
None of these
Other
78
Have you had any of these treatments?* This field is required.Select all that apply
Back surgery
Neck surgery
Back bracing
Spinal injections
Physical Therapy
Chiropractic
None of these
Other
79
List all major illnesses that you have or have had:* This field is required.(glaucoma, diabetes, high blood pressure, heart attack, depression, etc.) Please list each illness on a separate line.
80
List all major surgeries you've had with the dates:* This field is required.Please list each surgery on a separate line.
81
List all medications and supplements you are currently taking:* This field is required.If none, type "None". Please list each medication on a separate line.
82
List any medication allergies you have:* This field is required.If none, type "None". Please list each allergy on a separate line.
83
What is your height and weight?* This field is required.
84
Review of Systems* This field is required.Answer yes if you have issues with any of the following:
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
General/constitutional (fever, heat stroke, weight loss or gain, etc.)
Eyes (poor vision, eye pain, tearing, redness, etc.)
loss, weight gain, unusually tired)
Ears, nose, throat (hard of hearing, stuffy nose, earache, cough, dry mouth, etc.)
Cardiovascular (high bp, racing pulse, etc.)
Respiratory (congestion, wheezing, short of breath, etc.)
Gastrointestinal (stomach upset, diarrhea, constipation, hernia, ulcers, etc.)
Genital, kidney, bladder (painful urination, frequent urination, impotence, yellow jaundice, etc.)
Females: Are you pregnant or nursing?
Muscles, bones, joints (joint pain, stiffness, swelling, cramps, arthritis, etc.)
Skin (pimples, warts, growths, rash, etc.)
Neurological (numbness, headache, seizures, paralysis, etc.)
Psychiatric (anxiety, depression, insomnia)
Endocrine (diabetes, hypothyroid, etc.)
Blood/lymph (bleeding, cholesterolemia, anemia, problems related to blood transfusion, etc.)
Allergic/immunologic (sneezing, swelling, redness, itching, hives, lupus, etc.)
General/constitutional (fever, heat stroke, weight loss or gain, etc.)
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
1 of 16
85
Have you ever had a blood transfusion?* This field is required.
YESNO
86
Do you drink alcohol?* This field is required.
YESNO
87
How much alcohol do you typically drink?* This field is required.
88
Do you currently smoke?* This field is required.
YESNO
89
Are you a former smoker?* This field is required.
YESNO
90
How many packs per day?* This field is required.
Less than 1
1
2
3
More than 3
91
For how many years?* This field is required.
92
Family Medical History:* This field is required.Pleas choose all that apply
Arthritis
Back issues
Neck issues
Hypertension
Diabetes
Glaucoma
Cancer
Stroke
Heart Disease
Tuberculosis
Other Inheritable Diseases
Blood Transfusions
Other
93
Employment Status:* This field is required.
Employed
Unemployed
Homemaker
Retired
Disabled
Student
94
What is your occupation?* This field is required.If you are not currently working or retired, let us know what job you did have.
95
Have you missed any work because of your spinal condition?* This field is required.
YESNO
96
How many total days of work have you missed?* This field is required.
97
The following persons are authorized to obtain my medical records and prescriptions:
First Name
Last Name
Relationship
Phone
Person 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Person 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Person 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Person 1
Person 2
Person 3
First Name
Row 0, Column 0
Last Name
Row 0, Column 1
Relationship
Row 0, Column 2
Phone
Row 0, Column 3
First Name
Row 1, Column 0
Last Name
Row 1, Column 1
Relationship
Row 1, Column 2
Phone
Row 1, Column 3
First Name
Row 2, Column 0
Last Name
Row 2, Column 1
Relationship
Row 2, Column 2
Phone
Row 2, Column 3
1 of 3
98
Family History of Substance Abuse* This field is required.
Alcohol
Illegal Drugs
Perscription Drugs
None
99
Personal History of Substance Abuse* This field is required.
Alcohol
Illegal Drugs
Perscription Drugs
None
100
Are you between 16-45?* This field is required.
YESNO
101
Do you have a history of preadolescent sexual abuse?* This field is required.
YESNO
102
Do you have any mental health disorders?* This field is required.For example: ADD, Bipolar Disorder, OCD, etc.
YESNO
103
Do you suffer from depression?* This field is required.
YESNO
104
Southeastern Spine Protected Health Information Use and Authorization* This field is required.
105
Southeastern Spine Telehealth Consent* This field is required.
106
Disclosure of Ownership in Southeastern Spine Institute Ambulatory Surgery Center, LLC* This field is required.
107
Southeastern Spine Patient Medication Agreement* This field is required.
108
Southeastern Spine Notice of Privacy Practices* This field is required.
109
Southeastern Spine Policy for Patient Care Services* This field is required.
110
Southeastern Spine Authorization and Assignment of Insurance Benefits* This field is required.
Should be Empty: