New Patient Demographics Form

New Patient Demographics Form

Kunj Patel Medical Doctor PC DBA CRISSP Longevity Clinic
How did you hear about us?*
Other: (Please specify)*
Today's Date

MonthDayYear
Date
Patient's Name*

First NameLast Name
Date of Birth (MM-DD-YYYY)*
Age:
Social Security No.
Gender:*

MaleFemaleOther
Marital Status:*

SingleMarriedDivorcedWidowedOther
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
I agree to receive emails, text messages, and phone calls, which may be recorded and/or sent using automated dialing or emailing equipment or software unless I opt-out from such communications. I also agree to the Terms of Use and Privacy Policy linked below. I understand that my consent to be contacted is not a requirement to purchase any product or service and that I can opt-out at any time. Reply STOP for STOP and HELP for help for more information. Message & data rates may apply. Message frequency varies.*
Email Address:
Occupation:
Employer:
Emergency Contact Name:*
Home Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Please upload or take a photo of your Driver's License or other ID card (Front):

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Driver's License or ID card (Front):
REFERRING DOCTOR'S INFORMATION
Referring Doctor's Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
PRIMARY CARE DOCTOR'S INFORMATION
Primary Care Doctor’s Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
PREFERRED PHARMACY INFORMATION
Do you have a preferred pharmacy? If yes, please list them below.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
HEALTH INSURANCE INFORMATION
Primary Insurance Plan Name:
Primary Insurance ID Number:
Group Number:
Policy Holder Name:
Policy Holder Date of Birth:
Patient’s Relationship to Policy Holder:
Please upload or take a photo of your Insurance ID card (Front):

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Please upload or take a photo of your Insurance ID card (Back):

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Insurance ID card (Front):
Insurance ID card (Back):
Secondary Insurance Plan Name:
Secondary Insurance ID Number:
Group Number:
Policy Holder Name:
Policy Holder Date of Birth:
Patient’s Relationship to Policy Holder:
Please upload your insurance ID (Front):

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Please upload your insurance ID (Back):

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Insurance ID card (Front):
Insurance ID card (Back):
AUTHORIZATION & ASSIGNMENT OF BENEFITS: I, the undersigned hereby authorize the performance of such services deemed medically necessary to diagnose and treat my condition(s). Further, I authorize my insurance benefits to be paid directly to CRISSP Longevity Clinic DBA for Kunj Patel Medical Doctor PC. I understand that I am financially responsible for any co-payments, deductibles or uncovered amounts. I authorize Crissp to release any information necessary for the purpose of processing claims with my insurance company. I hereby order all parties to accept a copy of this authorization in lieu of the original.*
MEDICAL HISTORY
PAST MEDICAL HISTORY
Please list all of your previous and current medical condition (e.g. Heart attack, asthma, etc.).
Please list all of your previous and current medical condition (e.g. Heart attack, asthma, etc.).
PAST SURGICAL HISTORY
Have you ever had any surgical procedures done?

YesNo
Heart Surgery

Valve ReplacementAneurysm RepairStent PlacementVascular SurgeryNot ApplicableOther
If so, please indicate the date, type, and any pertinent details.
Joint Surgery

ShoulderHipKneeNot ApplicableOther
If so, please indicate the date, type, and any pertinent details.
Spine/Back Surgery

DiscectomyLaminectomySpinal FusionNot ApplicableOther
If so, please indicate the date, type, and any pertinent details.
Do you have any other surgeries done?
If so, please indicate the date, type, and any pertinent details.
CURRENT MEDICATIONS
Are you currently taking any medications?

YesNo
Are you currently taking any blood-thinners or anticoagulants?

YesNo
If yes, which one?

PlavixCoumadinEliquisAspirinNot ApplicableOther
Please list all medications you are currently taking including the dose and frequency.
ALLERGIES
Do you have known drug allergies?

YesNo
If so, please list all medications you are allergic to and the allergic reaction.
Topical Allergies

IodineLatexTape
Are you allergic to contrast?

YesNo
FAMILY HISTORY
Do you have any significant family medical history?

I have no significant family medical historyI am adopted/No family medical history availableYes I have

Height:
Weight:
Please circle your current overall LEVEL OF HEALTH

1

2

3

4

5

6

7

8

9

10

1 is Very poor health, 10 is Excellent health
Please rank the top 3 areas you would like to improve with 1 being the most important and 3 the least important.
Sleep
Exercise
Substance Use
Weight Management
Purpose & Connection
Nutrition
Mental health

0 - Not important at all; 10 - Very important

Rows	0	1	2	3	4	5	6	7	8	9	10
How IMPORTANT is it for you to make the change you ranked as the #1 most motivated topic area to address?
How CONFIDENT are you regarding your ability to make the change you ranked as the #1 most motivated topic area to address?
How IMPORTANT is it for you to make the change you ranked as the #2 most motivated topic area to address?
How CONFIDENT are you regarding your ability to make the change you ranked as the #2 most motivated topic area to address?
How IMPORTANT is it for you to make the change you ranked as the #3 most motivated topic area to address?
How CONFIDENT are you regarding your ability to make the change you ranked as the #3 most motivated topic area to address?

What would you like to gain from this lifestyle/longevity visit? (Check all that apply)

More medical/scientific knowledgeAccountabilityPractical health tipsPersonalized planOther

Please answer based on your sleeping patterns OVER the LAST TWO WEEKS

Rows	Never	Seldom	Sometimes	Often	Always
How often have you had difficulty staying awake during routine tasks?
How often have you had difficulty staying awake while driving?
How often have you felt fatigued or needed to nap during the day?
How often has it taken you more than 30 minutes to fall asleep at night?
How often have you woken up at night?
How often have you unintentionally woken up early in the morning?
How often do you look at a screen within 2 hours of sleeping (i.e. TV, computer, iPad, or Phone)?
How often have your legs or arms jerked during sleep?
How often have you experienced "creeping" or "crawling" feelings in your legs?
How often have you snored loudly, gasped, choked, or stopped breathing during sleep?
How often have you used sleeping aids (i.e. tobacco, alcohol, over-the-counter medications, or prescription medications) to help you fall asleep?
Do you have a job that requires night shifts?
Do you have a medical condition or chronic pain that interferes with your sleep?
On an average weekday do you get at least 7-8 hours of sleep in a 24-hour period?
On an average weekend do you get at least 7-8 hours of sleep in a 24-hour period?

NUTRITION

EATING PATTERNS Please answer based on your typical eating habits

Rows	0	1	2	3	4+
On average, how many cups (8 oz.) of caffeinated beverages do you drink per day (tea, soda, coffee, or energy drinks)?
On average, how many servings of alcohol do you drink per day?
On average, how many cups (8 oz.) of sugary drinks (soda, sports drinks, juice) do you drink per day?
On average, how often do you snack on convenience or "junk" food per day? (i.e. chips, candy, granola bars, crackers, cookies, etc.)
On average, how many meals do you buy from a restaurant or fast food per week?
On average, do you drink at least 8 glasses of water per day?
On average, do you eat at least 5 handfuls of nuts per week?
Do you use natural or artificial sweeteners? (i.e. Equal, Stevia, Splenda, Sweet & Low, honey, agave, etc.)
Do you add salt to most of your meals?
Do you eat processed meats (i.e. sausage, hot dogs, salami, bacon)?

Do you have any bad reactions (sensitivities or allergies) to food?

YesNo
If yes, please list here:
Do you avoid any particular foods?

YesNo
If yes, please list here:
Do you have foods that you crave?

YesNo
If yes, please list here:
Are you currently following a particular diet or nutrition plan?

YesNo
If yes, please list here:
During the last 3 months, did you have any episodes of excessive overeating?

YesNo
If yes, please list here:
Are you concerned about making the wrong food choices?

YesNo
If yes, please list here:
Have you ever had an eating disorder?

YesNo
If yes, please list here:
Do you use any of the following VITAMINS or SUPPLEMENTS? (Check all that apply)

Vitamin DProbioticsCalciumOmega 3Vitamin B12MultivitaminOther
Other Vitamins or Supplements you are taking:
Do you use any of the following OILS with your meals or cooking? (Check all that apply)

Olive OilButterCoconut OilVegetable OilCanola OilLardOther
FOOD RECALL: Please record below what AND how much you ate and drank yesterday (or the last typical day)
Breakfast
Time

Hour Minutes

AM/PM Option
Lunch
Time

Hour Minutes

AM/PM Option
Dinner
Time

Hour Minutes

AM/PM Option
Snacks
Time

Hour Minutes

AM/PM Option
Drinks/Beverages
Time

Hour Minutes

AM/PM Option
WEIGHT MANAGEMENT

BEHAVIOR PATTERNS

Rows	Never	Seldom	Sometimes	Often	Always
How often do you skip meals?
How often do you snack in between meals?
How often do you eat while watching TV?
How often do you eat while in bed?
How often do you have difficulty sleeping?
How often do you lack physical activity or exercise?
How often do you feel a lack of purpose or meaning in your life?

Which of the following factors apply to your eating habits and current lifestyle? Check all that apply.

Like healthy foodFast eaterRely on packaged or fast foodsDo not plan mealsLate night eaterNo time to prepare healthy food choicesDon't like healthy foodEat slowlyDislike cookingEat a variety of foodsNegative relationship to foodDon't know how to cookKnow how to cook healthy foodsRead nutrition labelsPrepare meals at homeAlways hungryErratic eaterLive alone or eat alone ofter
Do any of the following situations or emotions cause you to eat? Check all that apply.

SadnessFatiguePainSocial or Family SituationsInsomiaBoredomAnxietyStress
Have you ever been overweight or obese?

YesNo

Are you currently trying to lose or gain weight?

YesNo
If yes, what is your goal:

Lose weightGain weight
Have you ever intentionally lost or reduced your weight by more than 5 lbs.?

YesNo
If yes, did you regain weight within 1 year?

YesNo
Have you had weight loss surgery?

YesNo
If yes, please list the type of surgery you had.
Have you ever used weight loss medications? If yes, circle which ones you have used? If other, please list.

AcutrimAlliAmphetaminesAnorexBelviqByettaContraveDexatrimDidrexFastinFenfluramineMazanorMeridiaObalanPhendietFen-PhenPhenterminePlegineProzacPondiminQsymiaReduxSanorexTenuateTepanolVyvanseWechlessWellbutrinXenicalI don't remember the name of the medicationOther
WEIGHT LOSS STATEGIES. Have you tried any of the following alternative therapies or programs? Check all that apply. If other, please list.

AcupunctureAcupressureNutritionist/Registered DietitianResidential ProgramsHypnosisPhysical Activity/ExercisesOther
Which commercial or fad diets have you tried in the past? Check all that apply. If other, please list.

Atkins DietLow FatCalorie CountingPaleoCHIPSouth BeachDASHVeganMediterranean DietElimination Diet (Allergy)Gluten FreeVegetarianJenny CraigWeight WatchersLow CarbSlim Fast/Meal ReplacementOther
EXERCISE
EXERCISE HABITS: AEROBIC/CARDIO TRAINING
During the average week, how many days do you exercise at a moderate to strenuous intensity (i.e. brisk walking or enough to break a light sweat)?
During an average session, how many minutes do you exercise at a moderate to strenuous intensity (i.e. brisk walking or enough movement to break a light sweat)?
List types of aerobic activities you do:

walkingjoggingswimmingbicyclingdancingOther
EXERCISE HABITS: STRENGTH/RESISTANCE TRAINING
During the average week, how many days do you do strength/resistance training?
How many minutes do you exercise with strength/resistance training?
List types of activities you do:

weightliftingPilateskettle ballresistance machinesexercise bandsOther
What MOTIVATES you or would motivate you to exercise? Check top three.

Nothing would motivate meFamily or partnerImprove moodWeight reductionControl Blood glucoseBody ImageIncrease EnergyReduce blood pressureDecrease stressPrevent heart diseasePrevent Bone lossImprove sleepIncrease self-esteemOther
Are there any BARRIERS or PROBLEMS that limit exercise? Check all that apply.

No barriersDepressionWork ResponsibilityCostLife Transition PeriodTimeFearFamily responsibilityApparelEnergyOther
EXERCISE SAFETY
Do you have any injuries that would make it difficult to exercise?

YesNo
If yes, please explain:
Do you have any joint, muscle, or bone problems that might get worse with exercise?

YesNo
If yes, please explain:
Do you have any breathing problems while exercising?

YesNo
If yes, please explain:
Do you have any balance problems or have had a fall in the last 6 months?

YesNo
If yes, please explain:
Do you have any difficulty completing your activities of daily living (i.e. showering, dressing, toileting)

YesNo
If yes, please explain:
Do you have any of the following health problems? Check all that apply.

Arrhythmia or irregular heartbeatArthritis or significant joint painChest pain/anginaUncontrolled diabetesSevere or uncontrolled heart failureUncontrolled asthmaRecent heart attackChronic or unusual fatigue/tirednessDifficulty breathing with activityOther
MENTAL HEALTH

PERCEIVED STRESS

Rows	Never	Seldom	Sometimes	Often	Always
How often have you felt that you were unable to control the important things in your life?
How often have you felt lack of confidence about your ability to handle your personal problems?
How often have you felt that things were not going your way?
Have often have you found it hard to let go of things that upset you?

How do you COPE with stress? Check all that apply.

MeditationExercise/Physical ActivityCounseling/PsychotherapySocializing with friends or familyFood (too much, too little)Spiritually/FaithSexRecreational drugs (i.e. marijuana, cocaine, etc.)Television and/or video gamesGamblingJournalingMassage/Body workPrayerSubstance (tobacco, alcohol)DistractionHuritng yourself (i.e. cutting, etc.)Pet therapyOther

RESILIENCE. When I am under extreme stress:

Rows	Never	Seldom	Sometimes	Often	Always
I find a way to learn from my experience.
I find a way to take action.
I find it easy to prioritize what is important in my life.
I look at a stressful situation as an opportunity to grow.
I meet the goals I set for myself.
I believe that there are a lot of ways around a problem.
I feel motivated to pursue my goals.
I know I can get through it.

MIND-BODY CONNECTION

Rows	Never	Seldom	Sometimes	Often	Always
I meet the goals I set for myself.
Do thoughts or feelings affect your physical health?
Could you be experiencing some emotion and not be aware of it?
Are you aware of tension in your body?
Do you notice how your body changes when angry?
Do you notice stress in your body?
Do you notice how your body reacts to emotions?

DEPRESSION. Over the last 2 weeks, how often have you been bothered by the following?

Rows	Not at all	Several days	Most days	Daily
Little interest or pleasure in doing things.
Feeling down, depressed or hopeless.
Trouble falling asleep, staying asleep, or sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself or that you're a failure or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching television.
Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead or of hurting yourself in some way.

ANXIETY. Over the last 2 weeks, how often have you been bothered by the following?

Rows	Not at all	Several days	Most days	Daily
Feeling nervous, anxious, or on edge.
Not being able to stop or control worrying.
Worrying too much about different things.
Trouble relaxing.
Being so restless that it's hard to sit still.
Becoming easily annoyed or irritable.

PURPOSE AND CONNECTION

How often do you agree with the following:

Rows	Never	Seldom	Sometimes	Often	Always
I live a purposeful and meaningful life
I have a spiritual community that I can turn to in times of need
I have a source of inner strength and meaning
I am satisfied with my current belief system
I have people who care about what happens to me
I have people who accept me at my worst and best
I have people I trust at home or work who I can talk to about my problems
I get help when I'm sick

SMOKING AND SUBSTANCE HISTORY
NICOTINE/TOBACCO (i.e. cigarettes, e-cigarettes, e-cigarettes/vaping, cigars, chew, snuff)
Do you use any of the nicotine products listed above?

YesNo
If yes, do you want to quit using the nicotine/tobacco products?

YesNo
If yes, how soon after you wake up do you use nicotine/tobacco?

After 60 minutes31-60 minutes6-30 minuteswithin 5 minutes
If yes, how many cigarettes do you smoke per day?

10 or less11-2021-3031+
What age did you start smoking?
What made you start smoking again?
What is the longest time period you have stayed quit?
How many times have you seriously tried to quit?
Which of the following people smoke around you? Check all that apply.

FriendsFamilyPartnerCo-WorkersOther
For your most recent quit attempt, how long did it last?
Who is supporting you to quit smoking?
What is your most important reason to quit smoking?
Are you currently using or have used any medications to help you quit smoking?

YesNo
If yes, check with of the following medications you have used:

Nicotine PatchNicotine GumNicotine LozengeWellbutrin/Bupropion PillChantix/Varenicline PillOther
If you used any of the medication listed above, did they help?

YesNo
If yes, list which ones helped:
Have you used any methods in the past other than medications to try to quit?

YesNo
If yes, check which of the following methods you have used:

Self-helpGradual reductionCold turkeyHypnosisAcupunctureSpecial filtersVaping/e-cigarettesOther
ALCOHOL
Do you drink alcohol?

YesNo
What type of alcohol do you prefer?
On average, how many servings do you drink per day/week/month/year on average?

Have you used Recreational drugs (cocaine, heroin, meth, etc.) in the past year?

YesNo
If yes, what level of concern do you have regarding use of the substances:

0

1

2

3

4

5

0 is No concern, 5 is High concern
If yes, how much substance do you usually use?
Have you used Marijuana in the past year?

YesNo
If yes, what level of concern do you have regarding use of the substances:

0

1

2

3

4

5

0 is No concern, 5 is High concern
If yes, how much substance do you usually use?

TREATMENT HISTORY

Rows	Yes	No
Have you ever received treatment for a mental health problem?
Have you ever received treatment for drug or alcohol use?

MEDICAL SYMPTOM QUESTIONNAIRE (MSQ)
This questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the PAST 30 DAYS. If you are taking after the first time, record your symptoms for the LAST 48 HOURS ONLY.

Point Scale:

0 = Never or almost never have the symptom

1 = Occasionally have it, effect is not severe

2 = Occasionally have, effect is severe

3 = Frequently have it, effect is not severe

4 = Frequently have it, effect is severe

Note: Optimal is <10; Mild Symptoms: 10-50; Moderate Symptoms: 50-100; Severe Symptoms: over 100

DIGESTIVE

Rows	0	1	2	3	4
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Nausea or vomiting

Total

EARS

Rows	0	1	2	3	4
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss

Total

HEAD

Rows	0	1	2	3	4
Headaches
Faintness or lightheadedness
Dizziness
Insomnia

Total

HEART

Rows	0	1	2	3	4
Irregular or skipped heartbeat
Chest pain
Rapid or pounding heartbeat

Total

JOINTS/MUSCLES

Rows	0	1	2	3	4
Pains or aches in joints
Arthritis
Stiffness or limitations of movement
Pain or aches in muscles
Feeling of weakness or tiredness

Total

LUNGS

Rows	0	1	2	3	4
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

Total

MIND

Rows	0	1	2	3	4
Poor memory
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty making decisions
Stuttering or stammering
Learning disabilities
Slurred speech

Total

EMOTIONS

Rows	0	1	2	3	4
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

Total

ENERGY/ACTIVITY

Rows	0	1	2	3	4
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

Total

EYES

Rows	0	1	2	3	4
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision (does not include near or far sightedness)

Total

NOSE

Rows	0	1	2	3	4
Stuffy nose
Sinus problems
Sneezing attacks
Excessive mucous formation
Hay fever

Total

SKIN

Rows	0	1	2	3	4
Acne
Hives, rashes, dry skin
Hair loss
Flushing or hot flushes
Excessive sweating

Total

WEIGHT

Rows	0	1	2	3	4
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating

Total

OTHER

Rows	0	1	2	3	4
Frequent illness
Frequent or urgent urination
Genital itch or discharge

Total
Total
Result
PREVENTIVE SERVICES
Have you had a physical exam and/or "Wellness" Visit in the past 12 months?

YesNoI don't know
If yes, list date and outcome:
Have you had a dental exam and teeth cleaning in the past 12 months?

YesNoI don't know
If yes, list date and outcome:
Have you been screened for diabetes with blood work?

YesNoI don't know
If yes, list date and outcome:
Have you had your cholesterol, lipids or triglycerides measured?

YesNoI don't know
If yes, list date and outcome:
Have you ever had a bone density test to check for osteoporosis?

YesNoI don't know
If yes, list date and outcome:
Do you have any balance problems or have had a fall in the last 6 months?

YesNoI don't know
If yes, list date and outcome:
Do you have any difficulty completing your activities of daily living (i.e. showering, dressing, toileting)?

YesNoI don't know
If yes, list date and outcome:
Do you have any concerns about your ability to drive safely or have you had any car accidents in the past 12 months?

YesNoI don't know
If yes, list date and outcome:
Do you have any concerns about your memory?

YesNoI don't know
If yes, list date and outcome:
Do you have any trouble with your hearing?

YesNoI don't know
If yes, list date and outcome:
Have you had your eyes checked for vision problems?

YesNoI don't know
If yes, list date and outcome:
Have you ever had your metabolism or thyroid checked?

YesNoI don't know
If yes, list date and outcome:
Have you ever been told that you have a sexually transmitted disease/infection?

YesNoI don't know
If yes, list date and outcome:
If you smoke, have you ever had an abdominal ultrasound to check for possible aneurysms?

YesNoI don't know
If yes, list date and outcome:
Have you ever received counseling behavioral therapy for any of the following problems?

Weight management or obesityNutritionSmoking or use of other nicotine productsAlcohol use
Which of the following screenings have you completed

Colon cancer screen (stool test or colonoscopyBreast cancer screen (mammogram)Cervical cancer screen (PAP smear)HIV/AIDS blood work screenHepatitis C blood work screenDepression or sadness screen
Have you had the following vaccines?

FluHepatitis BPneumococcal or Pneumonia
DIAGNOSTIC TESTS AND IMAGING
Did you have any diagnostic tests performed for your current pain complaints?

YesNo
MRI
Please indicate the Date and Facility
X-ray
Please indicate the Date and Facility
CT scan
Please indicate the Date and Facility
Dexa Body Composition Scan
Please indicate the Date and Facility
Others
Please enter the secure link where we can access the files
Please upload important files here

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Do you have pain?*

YesNo
If yes, where?

HeadNeckShoulderHips
You mentioned that you have areas of pain - would you like to give us a bit more detail with our In Depth Pain Questionnaire so that we can understand and address your issues?

YesNo
Where is your worst area of pain located?
Does this pain radiate? If yes, where?
Please list any additional areas of pain.
Approximately when did this pain begin?
What caused your current pain episode?

Motor Vehicle AccidentPersonal Injury (legal term describing injury sustained to your person by negligence of another)Other
How did your current pain episode begin?

GraduallySuddenly
Since your pain began, how has it changed?

DecreasedIncreasedStayed the same
Please indicate your average daily pain score.

1

2

3

4

5

6

7

8

9

10

1 is Lowest, 10 is Highest
Please indicate your worst daily pain score.

1

2

3

4

5

6

7

8

9

10

1 is Lowest, 10 is Highest
Check all that describe your pain.

AchingCrampingDullTingling/Pins and NeedlesHot/BurningNumbnessShock-likeShootingSpasmingSqueezingSharpThrobbingTiring/Exhausting
What word best describes your pain?

ConstantIntermittent
When is your pain at its worst?

MorningDuring the dayEveningsMiddle of the night

Other Activities:
In the past three months, have you developed any new:

Fevers/ChillsBladder IncontinenceBowel IncontenenceUnintentional weight lossNumbness/Tingling in the genital regionProgressive WeaknessBalance ProblemsDifficulty WalkingNone
Other Doctors Consulted for your current pain. (Only for pain relief)

AcupuncturistAnesthesiologistChiropractorDentistEndocrinologistENT PhysicianGeneral PhysicianHypnotistInternistNeurologistNeurosurgeonOphthalmologistOrthopedic SurgeonPain PhysicianPhysical TherapistPlastic SurgeonPodiatristPsychiatrist/PsychologistRheumatologist
If you saw a physical therapist, when did you go and for how long?
If you saw a Chiropractor, when did you go and for how long?
Chiropractor's Name:
Chiropractor's Contact Number:
Please enter a valid phone number.Format: (000) 000-0000.
INTERVENTIONAL PAIN TREATMENT HISTORY

Joint Injection –Joint(s)
Nerve Blocks - Area/Nerve(s)
Trigger Point Injection – Where?
Vertebroplasty/Kyphoplasty–Level(s)
Other
TREATMENTS FOR PAIN RELIEF

ANESTHESIA HISTORY
Have you ever had anesthesia (Sedation for a surgical procedure)?

YesNo
If so, have you ever had any adverse reaction to anesthesia?

YesNo
From what type of anesthesia did you react adversely to? Please check all that apply.

Local AnesthesiaEpiduralGeneral AnesthesiaIV SedationNot applicable
Please explain briefly.
Do you have a family history of adverse reactions to anesthesia? If so, to which of the following?

Local AnesthesiaEpiduralGeneral AnesthesiaIV SedationNot applicable
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Rows	Arthritis	Cancer	Diabetes	Headaches	Heart Disease	High Blood Pressure	High Cholesterol	Kidney Problem	Liver Problems	Osteoporosis	Rheumatoid Arthritis	Seizure	Stroke
Father
Mother
Grandfather
Grandmother
Sibling#1
Sibling#2

Rows	Yes	No
Were you overweight as a child?
Were you overweight as a teenager?
Were you overweight between the ages of 20-29?
Were you overweight between the ages of 30-39?
Were you overweight above the age of 40?

Rows	Yes	No
Have you ever felt you should "Cut down" on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had a drink in the morning to steady your nerves or to get rid of a handover (eye opener)?
Do you binge drink (more than 5 drinks for men or 4 drinks for women within 2 hours)?

Rows	Increases my pain	Decreases my pain	No change in my pain
Bending Forward
Bending Backward
Changes in Weather
Climbing Stairs
Walking
Lifting Objects
Lying on your Back
Lying on your Stomach
Rising from a Sitting Position
Sitting
Standing
Driving
Coughing/Sneezing

Rows	Cervical	Thoracic	Lumbar	Not Applicable
Discogram
Epidural Steroid Injection
Medial Branch Blocks or Facet Injections
Radiofrequency Ablation
Spinal Column Stimulator

Rows	Helped Pain	Worsen	No Change
Acupuncture
Biofeedback
Brace Support
Chiropractic Treatment
Hot/Cold Packs
Injection Therapy
Massage Therapy
Medications
Physical Therapy
TENS Unit
Traction

New Patient Demographics Form

REFERRING DOCTOR'S INFORMATION

PRIMARY CARE DOCTOR'S INFORMATION

PREFERRED PHARMACY INFORMATION

HEALTH INSURANCE INFORMATION

MEDICAL HISTORY

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

CURRENT MEDICATIONS

ALLERGIES

FAMILY HISTORY

NUTRITION

WEIGHT MANAGEMENT

EXERCISE

MENTAL HEALTH

PURPOSE AND CONNECTION

SMOKING AND SUBSTANCE HISTORY

MEDICAL SYMPTOM QUESTIONNAIRE (MSQ)

PREVENTIVE SERVICES

DIAGNOSTIC TESTS AND IMAGING

INTERVENTIONAL PAIN TREATMENT HISTORY

TREATMENTS FOR PAIN RELIEF

ANESTHESIA HISTORY

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