New Patient Information

Patient's Name *

First Name Last Name

Throughout this form please select for each question all answers that apply. It can be more than one answer per question.

DOB (Type in Date) *

Date Date Picker Icon

Email

example@example.com

This Form was completed by:

Self

If Other why?

Ease/convenience Time Patient not capable Patient doesn't speak english

Gender *

Male Female

Height -feet

Height-inches

Weight *

Insurance Type *

Health Insurance Workers Comp MVA / Personal Injury (Not Workers Comp)/Auto type Self Pay

Insurance

What is the main reason for your visit today? *

Your doctor will determine the treatment options for you after the full consultation. There may or may not be any surgical solutions for your problem but in general:

If your condition were one that might be benefited from surgery would surgery be an option you would consider at all?

Yes No

Please explain

Have you any serious medical issues or age related concerns that would prohibit or limit the option of any form of surgery?

Yes No

If there are non operative and surgical options for your condition would you most likely desire to try non operative options first?

Yes No

Have your symptoms that you seek treatment for have been going on for a very long time i.e. for more than a year?

Yes No

What prompted you to seek care now?

Is your appointment requested due to issues or problems getting pain medications renewed by your doctor?

Yes No

Please explain

Are you needing help with getting long term disability documentation or paperwork completed?

Yes No

Please explain

Do you still have the symptoms that led to your doctor seeking care for you with our team?

Yes No

Please explain why you desire the consultation if the symptoms are resolved.

If you have more than one area of your body that is bothering you and that you seek care for which is the most bothersome and that you would want treated first if we must focus on one area at a time? (click not applicable if this doesn't apply to you. If it does then type in the area you would like to be treated first.)

Not Applicable

Do you have any of the following. (Click any that apply)

Please explain the autoimmune disorder.

Are you on anticoagulant or anti-platelet medication that you were told could not be held at this time even short term?

Yes No

Please Explain

Do you have a case manager?

Yes No

Who is your case manager?

Was this caused from a person injury (Not Workers Comp) or a car accident?

Yes No

Date Of Injury

Date Date Picker Icon

Do you have an attorney?

Yes No

Are you planning on getting a lawyer?

Yes No

Who's your attorney?

Please explain why not.

What happened?

Work Status:

Working normal job despite problem(s) Light duty due to problem(s) Off work due to problem(s) Retired Disabled long term

Since when?

Please explain why.

How long have you been disabled?

What type of occupation do you do?

Professional Sedentary-office, sales, education etc Physical work- light to moderate Physical work -heavy Retired Disabled

What is your occupation?

Have you had spinal surgery in the last 3 months from another provider?

Yes No

Have any of your family members been in treated in our clinic? *

yes no

Name of Family member treated in our clinic.

Are you or have you seen any other specialists for this condition? *

yes no

List the names and specialties of any other doctor(s) you have seen for The current problem for which you are here for treatment

Have you had an electrodiagnostic testing called an EMG/NCV ? This is where they stimulated your nerves with little electrodes and muscles with little needles.

Yes No

When did you have it?

Within last 12 months 1-2 years 2 years plus

Where was the EMG performed?

Who performed the EMG?

Have you had any neurological surgery in the same area of the spine?

Yes No

What year?

Who was the doctor?

Please list the surgery(s) , when you had it, and who did the surgery?

Where did you have the surgery?

Have you had other neurological or spine surgeries on other areas?

Yes No

Please list the surgeries you have had.

Have you been in pain management or currently in pain management for this condition?

Yes No

Who have you been seeing?

When did you start seeing them?

Are you still with the pain clinic?

Yes No

When did you stop and why?

Have you been in within the last 3 years or are currently in pain management for any other condition?

Yes No

Who have you been seeing?

When did you start seeing them?

Have you been on any of these medications for more than 2 weeks anytime in the last 3 months? (Click all that apply)

Please tell us who prescribed it and when you started it.

Are you on any Neuropathic medications?

None Gabapentin (neurontin) Cymbalta Lyrica Elavil

Have you tried any neuropathic medications in the past for your problem but stopped taking?:

None Gabapentin (neurontin) Cymbalta Lyrica Elavil

Why did you stop the medications(s)?

Are you on any NSAIDS for this problem?

Yes No

Please tell us what NSAIDS you have take.

Are you on any other medications for this condition?:

Yes No

Please tell us what you have taken.

Have you seen another neurosurgeon or orthopedic spine surgeon for this issue in the last 3 months?

Yes No

Please list who you have seen and when you saw them.

Have you had prior surgeries in the area you are wanting treated?

Yes No

What type of surgery, who did it, and when was it done?

Has this problem had any of the following treatments?(Check all that Apply):

Physical Therapy Chiropractic treatments Spinal Injections by specialist(Not a muscle steroid shot at pcp office) Injection in the muscle in the pcp office.

Where did you go to Physical Therapy?

Are you still in Physical Therapy?

Yes No

When did you stop Physical Therapy?

Did Physical Therapy help?

Yes No

Who is your Chiropractor?

What area was treated?

Cervical spine Thoracic spine Lumbar Spine

What area was treated?

Cervical spine Thoracic spine Lumbar Spine

What type of Injection(s) did you have?

Epidural Steroid Injection Facet Injections Medial Branch Block Rhizotomy Si Injection Selective Nerve Root Block

How many Epidural Steroid Injections did you have?

1 2 3

Who did the Epidural steroid injection?

Where was these injections done?

When did you have the injection?

Was this done in a center your X-ray guidance with you lying down on a table?

Yes No

Which Side did you have it on?

Right Left Bilateral

Did it help?

Yes No

How long did the injection help?

When did you have the Facet injection?

Did it help?

Yes No

How long did the Facet injection help?

When did you have the Medial Branch Blcock?

Which Side did you have the medial branch block on?

Right Left Bilateral

Which Side did you have it on?

Right Left Bilateral

Did it help?

Yes No

How long did the injection help?

When did you have the Rhizotomy?

Which Side did you have the Rhizotomy on?

Right Left Bilateral

Did it help?

Yes No

How long did the injection help?

When did you have the SI injection?

Which Side did you have the SI Injection on?

Right Left Bilateral

Did it help?

Yes No

How long did the injection help?

When did you have the Selective Nerve Root Block?

Which Side did you have it on?

Right Left Bilateral

Did it help?

Yes No

How long did the injection help?

When did you have the Procedure?

Did it help?

Yes No

How long did the injection help?

Was this done in a center your X-ray guidance with you lying down on a table?

Yes No

What area did you have the injection?

Neck Lower back Thoracic area SI joint

Have you had any of these imaging test on the this problem in the last year?: Click all that apply

MRI CT Myelogram/CT

Where did you have your MRI and When did you have it?

Where did you have your CT and When did you have it?

Where did you have your myelogram/CT and When did you have it?

Are you currently in a nursing facility?

Yes No

Are you currently incarcerated?

Yes No

Check any of the following illness? (Check all that apply):

Severe Depression Schizophrenia Bipolar disorder Anxiety Disorder PTSD

Is your lower back pain (click all that apply)

In the upper lumbar area (just below rib cage area) Mid lumbar area (about the navel) Lower back lumbar area (just above the pelvis) Very low area around tailbone In buttocks area In hip area All of the above

Which side is the pain located in your leg? *

Right Left Both

Which side is the pain located in your hip/buttock. *

Right Left Both

Rate your average level of pain in your back. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in your back at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Location of left leg pain. *

Front of leg back of leg lateral (outside) side of leg medial (inner) side of leg

Location of Right leg pain. *

Front of leg back of leg lateral (outside) side of leg medial (inner) side of leg

Where does the Left leg pain go? *

Hip Thigh Knee Ankle Foot

Where does the Painleg pain go? *

Hip Thigh Knee Ankle Foot

When did your right leg pain start?

Rate your average level of pain in right leg *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in right leg at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your Left leg pain start?

Rate your average level of pain in Left leg *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in Left leg at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your Left buttock pain start?

Rate your average level of pain in Left buttock *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in Left buttock at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your Right buttock pain start?

Rate your average level of pain in Right buttock *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in Right buttock at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your Right Hip pain start?

Rate your average level of pain in Right Hip *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in Right Hip at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your Left Hip pain start?

Rate your pain in Left Hip at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in Left Hip. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Please describe your current symptoms. (If your current symtom is pain ,please put the area of your pain and where the pain radiates to. Also list any associated symptoms. ex. numbness, tingling, etc) *

What was the onset of Symptoms *

Sudden Slowly Developing

Any numbness? *

Yes No

Location of Numbness *

Any Weakness? *

Yes No

Location of Weakness *

Is your pain *

Constant Off and On

(Check all that apply) When your pain is present does it feel *

Sharp Deep Superficial Burning Electric Shock-like

What makes your symptoms worse? *

What makes your symptoms Better? *

What area bothers you more severely, when it hits, the back or lower extremity symptoms?

Back Lower Extremity Pain Both the same

Which area bothers you more frequently the back area or the lower extremity symptoms?

Back Lower Extremity Pain Both the same

Which area bothers you to the degree that if you had to select either the lower back pain or the radiating leg(s) pain to resolve first because it wasn’t possible to resolve both at the same time which would it be... the lower back pain or the radiating leg pain that you would want treated and resolved first ?

Back Lower Extremity Pain Both the same

Do you have any problems with walking?

Yes No

Check all that applies:

Poor Balance Clumsiness of walking Legs stiff Poor control of legs Very painful to walk Moderately painful to walk Mild pain to walk Have to walk stoop forward due to pain Have to walk stooped forward to to legs getting numb.

For this area of your spine did spinal injections treatments of any kind, if you had any of these performed in the past, help you enough that you would consider trying this plan again if it is feasible?

Yes No

Is your neck pain located (click all that apply)

in the upper neck area just below your head mid neck area on the right mid neck area on the left lower neck area on the left lower neck area on the right entire neck

Which arm is hurting? *

Right Left Both

Where does the Left arm pain go? *

Shoulder Elbow Wrist Hand Fingers My whole arm hurts

Where does the Right arm pain go? *

Shoulder Elbow Wrist Hand Fingers

Which shoulder is hurting?

Right Left Both

Which hand is hurting?

Right Left Both

When did your neck pain start?

Rate your level of pain in your neck on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in your neck at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your Left Arm Pain start?

Rate your level of pain in Left Arm on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in Left Arm at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your right arm pain start?

Rate your level of pain in Right Arm on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in Right Arm at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your Right shoulder pain start?

Rate your level of pain in your right shoulder on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in your right shoulder at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your left shoulder pain start?

Rate your level of pain in your left shoulder on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in your left shoulder at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your left hand pain start?

Rate your level of pain in your left hand on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in your left hand at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

When did your right hand pain start?

Rate your level of pain in your right hand on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain in your right hand at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

How long has it been hurting? *

Date of onset if known?

Is the problem getting: *

More frequent Less frequent No change in frequency

Please describe your current symptoms. (If your current symtom is pain ,please put the area of your pain and where the pain radiates to. Also list any associated symptoms. ex. numbness, tingling, etc) *

What was the onset of Symptoms *

Sudden Slowly Developing

Any numbness? *

Yes No

Location of Numbness *

Any Weakness? *

Yes No

Location of Weakness *

Is your pain *

Constant Off and On

(Check all that apply) When your pain is present does it feel *

Sharp Deep Superficial Burning Electric Shock-like

Rate your pain when it is present and at its worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

What makes your symptoms worse? *

What makes your symptoms Better? *

Do you have any problems with walking?

Yes No

Check all that applies:

Poor Balance Clumsiness of walking Legs stiff Poor control of legs Very painful to walk Moderately painful to walk Mild pain to walk Have to walk stoop forward due to pain Have to walk stooped forward to to legs getting numb.

Do you have any problems using your hands?

Yes No

Check all that apply:

Numbness of hands and fingers Clumsiness of fingers and hands Poor coordination of fingers and hands Difficulty with fine motor skills of hands Weakness of hands and fingers

Which area bothers you more frequently the neck area or the upper extremity symptoms?

Neck Upper Extremity Pain Both the same

Which area bothers you more severely, when it hits, the neck area or the upper extremity symptoms?

Neck Upper Extremity Pain Both the same

Which area bothers you to the degree that if youhad to select either the neck or the upper extremity/arm symptoms to resolve first because it wasn’t possible to resolve both at the same time which would it be?

Neck Upper Extremity Pain Both the same

For this area of your spine did spinal injections treatments of any kind, if you had any of these performed in the past, help you enough that you would consider trying this plan again if it is feasible?

Yes No

Any other Neurological Complaint Please Explain.

Is this visit for Trigeminal Neuralgia or facial pain?

Yes No

Do you have pain in your face that starts very rapidly,lasts seconds to a few minutes and then stops suddenly?

Yes No

Do you have pain in your face that stays always on the same side of the face either the right or the left, but it does not cross over to the other side?

Yes No

Does the pain feel like it comes on rapidly then disappears rapidly with periods of time between episodes that may last minutes,hours or even days to weeks and even years?

Yes No

Does the pain feel like a "live wire" of electricity is rapidly touched to the affected side of the face and then rapidly removed?

Yes No

How long did you go to PT or been going to PT?

Does it feel like the pain can be triggered by such common things as eating,brushing the teeth,shaving,washing the face,cool air blowing on face,touching the face in particular areas etc?

Yes No

Does the pain usually stay in the same area or tegion of the face with recurrent episodes?

Yes No

Do you remember exactly when and where you were when you first started having the pain?

Yes No

Is your pain usually very brief in duration (seconds to minutes) often with recurrent episodes that is similar to getting your face it with a machine gun like firing from a taser gun?

Yes No

Does your pain involve feelings of electrical shocks, stabbing a knife, or a bolt of lightning?

Yes No

Since you had your first bout of facial pain have you had periods of time (weeks,onth and even years) when you were pain free?

Yes No

Have you taken any anti convulsant medications: Tegretol, Dilantin, neurontin, Trileptal, Topamax, Zonegran, baclofen etc for your pain?

Yes No

Did you experience any periods of major relief from any of these medications?

Yes No

Did you have to stop or cut back the dosage due to side efects from the medications?

Yes No

Are you currently on these medication?

Yes No

Have you had any percutaneous, surgical or radiosurgical treatments for facial pain?

Yes No

Did you get relief for at least a period of time before the pain recurred?

Yes No

Was the first onset of your pain spontaneous in onset without known precedent cause?

Yes No

Has the course of the painful episodes changed for the worse with time so that the frequency of bouts of pain has increased while time between bouts has decreased as time has gone by since the first painful episode?

Yes No

Does the pain feel like it is created just from opening and closing of the jaw?

Yes No

Do you have multiple sclerosis?

Yes No

Did your pain start in association with a outbreak of rash on your face (shingles)?

Yes No

Did your pain start with some trauma to the face?

Yes No

Did your pain start after a dental or facial surgery was done?

Yes No

Does the pain feel like it is constantly present without any interventing periods of freedom from pain?

Yes No

Does the pain feel like it involves both sides of the face?

Yes No

Does the face feel constantly numb or weak?

Yes No

Are you currently in PT?

Yes No

when was the last time that you went to PT?

what body parts did they work on?

Lower back Neck Thoracic spine Arms Legs Walking

Have you done Medx for his area?

Yes no

Have you had traction for this area?

Yes no

Which side is the pain located *

Right Left Both

What area of the Thoracic Spine hurts?

Upper Thoracic Spine on the right Upper Thoracic Spine on the left Mid Thoracic Spine on the left Mid Thoracic Spine on the right Lower Thoracic Spine on the left Lower Thoracic Spine on the right

Which side does the pain wrap into your ribs? *

Right Left Both

Rate your level of pain that is in your thoracic spine on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain that is in your thoracic spine at its worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain that runs around the right side of your chest on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain that runs around the right side of your chest at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain that runs around the left side of your chest on average. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

Rate your level of pain that runs around the left side of your chest at it's worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

What was the onset of Symptoms *

Sudden Slowly Developing

Explain your pain.

Is your pain *

Constant Off and On

(Check all that apply) When your pain is present does it feel *

Sharp Deep Superficial Burning Electric Shock-like

Rate your pain when it is present and at its worst. *

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Extreme Pain

What makes your symptoms Better? *

What makes your symptoms worse? *

Which bothers you more severely, when it hits,the pain in the mid spine (thoracic spine) or the wrap around radiating pain?

Pain in Mid back Pain that wraps around into the ribs Both the same

Which bothers you more frequently the pain in the mid spine (thoracic spine) or the wrap around radiating pain?

Pain in Mid back Pain that wraps around into the ribs Both the same

Which area bothers you to the degree that if youhad to select either the mid back/thoracic spine pain or the radiating wrap around chest pain to resolve first because it wasn’t possible to resolve both at the same time which would it be?

Pain in Mid back Pain that wraps around into the ribs Both the same

For this area of your spine did spinal injections treatments of any kind, if you had any of these performed in the past, help you enough that you would consider trying this plan again if it is feasible?

Yes No

What problems are you having that led your doctor to find the problem that you are here for?

How long have you had these problems?

When was the problem discovered?

What treatment if any have you had for this problem?

Have you had surgery for this problem in the past?

Yes No

Mark any or all imaging you have had for this problem>

CT MRI PET Scan None

What treatment if any have you had for this problem?

New Patient History

General Information

Back Section

Neck Section

Headache Section

Facial Pain Questionaire

Thoracic Spine Section

Neurological Section