PATIENT INTAKE

Dr. Munish Lal, MD
1. Patient Information
Your name:

First NameLast Name
Date of Birth:

MonthDayYear
Cell Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Email
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status:
Sex:

Other
2. Pain History
Where does it hurt most (body parts)?
When did this pain begin? (approximate date, month, year)
On a pain scale from 0 to 10, where 0 means no pain and 10 represents the worst pain imaginable, how would you rate your current pain level?

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Pain
Since your pain began how has it changed?   Improved   Worsened   Stayed the same

When is your pain at its worst?
Mornings    Daytime    Evenings    Middle of night     Always the same

How often does the pain occur?
Intermittent (comes and goes)    Changes in severity but always present     Constant
3. Injury History
Injury Date

MonthDayYear
1. Injury from: car accident, slip and fall, motorcycle, car vs pedestrian, car vs bicycle
2. In what city did this happen?
3. Immediately following the injury, did you experience nausea, vomiting, dizziness, blurred vision, etc? Please list:
4. List all treatments done with approximate dates:
5. Have you ever had pain/injury in this/these area(s) BEFORE this injury? YesNo

Please provide information on this section that applies only since your injury (auto accident).

Associated Symptoms

4. Limitations
Does your condition stop you from doing everyday activities, meeting friends, or having fun?
Please explain more. For example, does it affect your bathing, dressing, eating, walking, bending, holding things, driving, or playing sports?
5. Pain Treatment History: If you have had any, please list each treatment and the date you last received it
Epidural Steroid (not childbirth) Injection: Dates/Years
Facet Injections/ Medial Branch Blocks Dates/Years
6. Diagnostic Tests and Imaging
MRI of the: body part Dates/Years
X-Ray of the: body part Dates/Years
CT Scan of the: body part Dates/Years
7. Past Medical History

Mark the following conditions/diseases that you have been treated for in the past:
General Medical
Cancer
Diabetes
Cardiovascular/Hematologic
Gastrointestinal
Respiratory
Urological
Urological
Neuropsychological
Head/Ears/Eyes/Nose/Throat
Musculoskeletal/Rheumatologic
Other Diagnosed Conditions
8. Past Surgical History

Please list any surgical procedures you have had done in the past including date:

Please list all medications you are currently taking.

Do you currently use any anticoagulant or blood-thinning medications? For example, medications such as aspirin, warfarin
Blood thinner medication name(s):

Please list all pain medications that you have been taking.

Existing Allergies:
11. Family History
Mark all appropriate diagnoses as they pertain to your first-degree relatives:
12. Social History
Are you currently under worker’s compensation?
Tobacco Use:
Never used Current user Former user *
Alcohol Use:
Illegal Drug Use (not including marijuana):
Have you ever abused prescription medications?
13. Review of Systems

Mark the following symptoms you are experiencing today:
Constitutional:
Ears/Nose/Throat/Neck:
Cardiovascular:
Eyes:
Gastrointestinal:
Respiratory:
Musculoskeletal:
Genitourinary/Nephrology:
Neurological:
Who is filling out this questionnaire?

Other
Psychiatric:
I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.
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1. Patient Information