Paragon Pain Solutions Intake

Paragon Pain Solutions

Medical Intake Form
There is no need to fill out the intake form if you do not have a treatment session scheduled.

By booking an appointment with us you have taken a big step toward improving your health. Please fill out the following information as accurately as possible. Our intake form is thorough because I am thorough in my assessment and treatment. It is the only way to accurately determine how the various systems of your body are working together so that I can provide you with the personalized treatment that you deserve. It is an honor and a pleasure to serve you.

PLEASE NOTE: If the form will not submit, DO NOT REFRESH YOUR BROWSER - you will lose all progress. Check the required fields with asterisks at the beginning of the form (Name, Address, Phone, Email) and at the end of the form (Agreement to Terms Checkbox and Signature) and make sure that they are all filled out correctly before ciicking "Submit."
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*

Area CodePhone
Home Phone Number
Work Phone Number
Age
Years
Email*
example@example.com
Date

MonthDayYear
Date
Gender

MaleFemaleNon-BinaryPrefer Not to Answer
Sex Assigned at Birth

MaleFemalePrefer Not to Answer
Pronouns (check all that apply)

He/Him/HisShe/Her/HersThey/Them/TheirsNo Listed (please specify)Prefer Not to Answer
Occupation
Marital Status

MarriedSingleDivorced
Spouse's Name (if applicable)
Spouse's Occupation (if applicable)
How did you hear about Paragon Pain Solutions?
Please circle your area(s) of experienced pain:

Please rate your pain according to the scale above

	0	1	2	3	4	5	6	7	8	9	10

0 is Best, 10 is Worst

Have you ever been treated for the same condition?

YesNo
Were you admitted to the hospital?

YesNo
Describe how it feels:
(aching, cramping, dull, sore, deep, sharp, shooting, stabbing, stinging, tingling, burning, numbness, radiating - if so, where?)
How did the pain first start? How did it start this time, if this is not the first time you've felt it?
Sudden or gradual onset? Mechanism of injury?
How often does it bother you?

ConstantlyEvery nightEverydayEvery weekEvery monthOther
How long does it last once it's there?

AlwaysMinutes/hoursNo pattern
What specifically makes it worse?

Certain movements/activitiesTime of dayUpon wakingSleepingPosition
Do you have a diagnosis from a doctor?
If yes, list it and the name of the doctor.
Other therapies/remedies tried? Results?
Have you ever had any surgeries? Were they beneficial?
List any other health problems for which you are being treated:
Do you have any pre-existing injuries that relate to this present injury?

YesNo
If yes, please explain:
Activities of Daily Living

The objective of this section is to get a sense of what types of activities, movements, postures, positions, and exercise you engage in on a regular basis. This section is also intended to get a feel for the intensity and frequency with which you perform these activities.
Work Duties:
Household Duties:
Exercise, Activities, Hobbies:
Sleeping Position:
What do you believe caused, or is causing this condition?
On a scale of 1 - 10, how much effort are you willing to put in to achieve maximum healing?

12345678910
On a scale of 1-10, choose the level of stress you are experiencing on a regular basis:

12345678910
Medical History

ADD/ADHD/DyslexiaArthritisAllergies/Hay FeverAnxietyAsthmaAlcoholismAlzheimer's DiseaseAutoimmune DiseaseBirth DefectsBlood Pressure ProblemsBronchitisCancerCardiovascular DiseaseCarpal Tunnel SyndromeCholesterol, elevatedChronic FatigueChronic PainCirculatory ProblemsColitisDepressionDental ProblemsDepressionDiabetesDigestive IssuesDiverticular DiseaseDrug AddictionEating DisorderEpilepsyEmotional ProblemsEmphesymaEnvironmental SensitivitiesEyes, ears, nose, throat problemsFacial/Cosmetic SurgeryFibromyalgiaFood IntoleranceFrequent Colds/Sore ThroatsGastroesophageal Reflux DiseaseGenetic DiseaseGlaucomaGoutGrinding TeethHeadachesHeart DiseaseInfectionIrritable Bowel SyndromeJaw ProblemsKidney or Bladder DiseaseLarge Tonsils/AdenoidsLearning DisabilitiesLiver or Gallbladder Disease (stones)Memory LossMental IllnessMigraine HeadachesMouth BreathingNeurological ProblemsObesityOsteoporosisPneumoniaPrevious OrthodonticsPTSDSexually Transmitted DiseaseSkin ProblemsSinus ProblemsSpeech ProblemsStrokeTeeth RemovedThyroid TroubleTonsillectomy/AdenoidectomyTuberculosisUlcerUrinary Tract InfectionVaricose VeinsOther
Sleep

SnoringTrouble Falling AsleepTrouble Staying AsleepRestless SleepWakeup Feeling UnrefreshedNighttime UrinationOther
Medical (Men)

BPHInfertilityProstate CancerDecreased Sex DriveOther

Terms & Conditions
Release and Indemnification

I hereby authorize Paragon Pain Solutions PC to provide any and all information, copies, or records to any clinic, physician, lawyer, insurance company, or workman's compensation fund as deemed necessary. A copy of this authorization shall be considered as valid as the original.

I hereby authorize any physician to release any and all information and copies of all records to Paragon Pain Solutions as deemed necessary for treatment. A copy of this authorization shall be considered as valid as the original.

I give permission that photographs and video footage may be taken of me or my X-rays, CAT, or MRI scans during the course of treatment at Paragon Pain Solutions. These photographs are strictly to be used for treatment planning, or education for other healthcare practitioners and will not be displayed anywhere else without my written permission.

24 Hour Cancellation Policy

I understand that there is a 24 hour cancellation policy for scheduled appointments. Cancellation of a scheduled appointment must be made through the online scheduling portal, or by calling Paragon Pain Solutions. Failure to cancel without the minimum notice will result in the full charge for the cancelled or missed appointment. Cancellation for Mondays and the day after holidays must be made on the prior business day during normal business hours. Payment for the entire amount of the scheduled appointment will be expected regardless of the patient's arrival time.
I agree to the above terms & conditions*

YesNo
Signature*

Clear
Should be Empty:

Paragon Pain Solutions

Activities of Daily Living

Food Frequency

Terms & Conditions