• New Patient Questionnaire

    v 3.1

  • We're committed to helping you take your life back.

    Each patient we treat is a unicorn.

    This is why we take the time to collect information specific to them and where they have been as patients in their pain journey. 

    Accurate and speedy submission of this form ahead of your visit will mean that we will be able to see you more quickly on the day of your appointment and guarantee a higher quality of care for you overall. 

     

  • Please tell us about yourself (select all options that apply)*
  • Enter your Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • EMERGENCY CONTACT

    • Emergency Contact #1 
    • Format: (000) 000-0000.
    • Emergency Contact #2 
    • Format: (000) 000-0000.
    • Emergency Contact #3 
    • Format: (000) 000-0000.

  • PHARMACY

  • Format: (000) 000-0000.
  • Do you have a pharmacy card?*
  • Have you recently relocated to Delaware?*
  • Select the state you relocated from*
  • Do you have prior imaging for the condition we are seeing you for?*

  • Please be advised that we will need to view the original CD you obtained from the imaging facility. No copies of the CD will be permitted for review and any imaging reports submitted should be in paper form only.

  • Was it done in Delaware?*
  • You indicated that you are new to pain management: have you had narcotics prescribed to you in the last 45 days?*
  • You indicated that you were seen at prior pain management, were you ever a patient of Sussex Pain Relief Center?*
  • You indicated that you have been a prior patient of Sussex Pain Relief Center, have you seen any other pain management since then?*

  • Pain Management

  • Format: (000) 000-0000.
  • When were you last seen by them? [An approximate date is acceptable]*
     - -
    2 digit month, 2 digit day, 4 digit year

  • AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

    Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028

  • I authorize release of my medical record(s) from

  • Format: (000) 000-0000.

  • Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

    Address: 18229 Dupont Blvd, Georgetown, DE 19947
    Fax: (302) 253-8028

    Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

    Please send a Letter of Discharge if available.

    CONSENT
    I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services. Please be advised we may update the address and fax number of the physician or provider facility as necessary.
     

    NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Enter the Date of Injury*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Which type of accident were you injured in?*
  • Is the case still active?*
  • Have you injured that body part prior to the Date of Injury?*
  • Did you seek medical assistance after the Date of Injury?*
  • Were you driving the vehicle at the time of injury?*
  • Were you wearing a seat belt?*
  • Did the airbags deploy?*

  • ORTHOPEDIC SURGEON

  • Have you seen an Orthopedic Surgeon?*
  • Format: (000) 000-0000.

  • AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

    Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028

  • I authorize release of my medical record(s) from

  • Format: (000) 000-0000.

  • Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

    Address: 18229 Dupont Blvd, Georgetown, DE 19947
    Fax: (302) 253-8028

    Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

     

    CONSENT
    I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services. Please be advised we may update the address and fax number of the physician or provider facility as necessary.

     

    NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • NEUROSURGEON

  • Have you seen a Neurosurgeon?*
  • Format: (000) 000-0000.

  • AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

    Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028

  • I authorize release of my medical record(s) from

  • Format: (000) 000-0000.

  • Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

    Address: 18229 Dupont Blvd, Georgetown, DE 19947
    Fax: (302) 253-8028

    Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

     

    CONSENT
    I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services. Please be advised we may update the address and fax number of the physician or provider facility as necessary.

     

    NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • RHEUMATOLOGIST

  • Have you seen a Rheumatologist?*
  • Format: (000) 000-0000.

  • AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

    Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028

  • I authorize release of my medical record(s) from

  • Format: (000) 000-0000.

  • Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

    Address: 18229 Dupont Blvd, Georgetown, DE 19947
    Fax: (302) 253-8028

    Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

     

    CONSENT
    I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services. Please be advised we may update the address and fax number of the physician or provider facility as necessary.

     

    NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • CHIROPRACTOR

  • Have you seen a Chiropractor?*
  • Format: (000) 000-0000.

  • AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

    Sussex Pain Relief Center || Phone: (302) 514-7246 || Fax: (302) 253-8028

  • I authorize release of my medical record(s) from

  • Format: (000) 000-0000.

  • Please send my medical record(s) to Sussex Pain Relief Center, LLC as I am consulting a pain specialist.

    Address: 18229 Dupont Blvd, Georgetown, DE 19947
    Fax: (302) 253-8028

    Please release office notes from my last three visits, imaging report(s) from the last three years, any lab reports from the last year, as well as a recent H&P.

     

    CONSENT
    I authorize the release of all information indicated, and I am aware that the records released may contain information relating to psychiatric or psychological testing, physical abuse, or drug and alcohol abuse. If treatment is for substance abuse, I understand that my records are protected under the federal regulations governing confidentiality of Alcohol & Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that my records are also currently protected under the Federal privacy regulations within the Health Insurance Portability and Accountability Act (HIPAA), 45 C.F.R. Parts 160 & 164. I understand that my health information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may redisclose the information and it may no longer be protected by the HIPAA privacy law. I authorize the release of HIV/HTLV/AIDS test results. The Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, noted above, however, will continue to protect the confidentiality of information that identifies me as a patient in an alcohol or other drug program from redisclosure. I understand that the covered entity seeking this authorization is permitted under the HIPAA regulations, in treatment, payment, enrollment or eligibility for benefits, and that by refusing to sign this authorization, I may be responsible for payment of services and/or may not be able to receive services. Please be advised we may update the address and fax number of the physician or provider facility as necessary.

     

    NOTE: This consent is valid for 90 days. It may be revoked by the signer at any time.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • PAIN HISTORY

  • When did the pain first start?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Where does your Primary Pain radiate to?*

  • PAIN HISTORY

    Primary Pain Continued
  • Describe your pain (Select all that apply)*
  • Which activities bring on or worsen your pain?*
  • Which activities seem to improve your pain?*
  • How does pain affect your sleep?*

  • PAST PAIN TREATMENT

    Describe what you have tried in the past for your pain. Let us know what helped.
  • Do you have a spinal cord stimulator or pain pump implanted?*

  • Please be advised that you will be expected to bring a copy or a picture of your device card to your first visit. 

  • Have you had problems with Conscious Sedation?*
  • Have you had problems with Anesthesia?*

  • PAST MEDICAL

  • Have you ever been diagnosed with or treated for any of the following health problems?*
  • Are you on benzodiazepines or anticoagulants?*

  • ALLERGIES

  • Are you allergic to Iodine Contrast Dye (e.g. IVP Dye)?*
  • Are you allergic to Aspirin or Anti-Inflammatory Medication?*

  • SURGICAL & HOSPITAL HISTORY

  • Have you previously had surgery?*
  • List past surgeries and the date(s) of the surgery [Click the + to add text lines]*
  • Have you been to the hospital in the last 30 days?*

  • FAMILY HISTORY

  • Does anyone in your immediate family (mother, father, sisters, brothers, grandparents) have any of the following:*
    Rows

  • WELCOME LETTER & PRACTICE POLICIES

  • Sign below to indicate you are aware that you may not be prescribed pain medication during your initial doctor's visit, as the decision to prescribe medication is at the discretion of the healthcare provider, who assesses the individual's medical history, symptoms, and overall health before determining the most appropriate course of action.

  • Please read a letter a Welcome Letter from our Chief Practitioner and Founder regarding practice policies.

    Please be advised that you are expected to submit this form in a timely fashion.

  • SOCIAL HISTORY

  • What's your marital status?*
  • Whom do you live with?*
  • Do you drink alcohol?*
  • Do you use illicit drugs?*

  • WE MAY NEED TO CONTACT YOU

    Let us know how you would like us to reach out to you and when you're available
  • Format: (000) 000-0000.
  • What's your preference?*
  • When can we get in touch with you?*
  • Please select any of the following options that are applicable:*
  • Should be Empty: