New Patient Information

Patient's Name*

First NameLast Name

What is the year of your birth?

What is the Month of your birth?

What is the day of your birth?

Email

example@example.com

SelfOther

MaleFemale

Height -feet

Height-inches

Weight*

Insurance

YesNo

Please select the body area you would like treated FIRST*

Please select the body area you would like treated SECOND*

Please select the body area you would like treated THIRD*

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:

YesNo

Please explain

YesNo

Please Explain

YesNo

What prompted you to seek care now?

YesNo

Please explain

YesNo

Please explain

YesNo

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

Please explain the autoimmune disorder.

YesNo

Please Explain

YesNo

Who is your case manager?

YesNo

Date Of Injury

Date

YesNo

Who's your attorney?

Please explain why not.

What happened?

Since when?

Please explain why.

How long have you been disabled?

What is your occupation?

YesNo

yesno

Name of Family member treated in our clinic.

yesno

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

YesNo

Within last 12 months1-2 years2 years plusOther

Where was the EMG performed?

Who performed the EMG?

YesNo

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?

YesNo

Please list the surgeries you have had.

YesNo

Who have you been seeing?

When did you start seeing them?

YesNo

When did you stop and why?

YesNo

Who have you been seeing?

When did you start seeing them?

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

Why did you stop the medications(s)?

YesNo

Please tell us what NSAIDS you have take.

YesNo

Please tell us what you have taken.

YesNo

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

YesNo

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

YesNo

Physical TherapyChiropractic treatmentsSpinal Injections by specialist(Not a muscle steroid shot at pcp office)Injection in the muscle in the pcp office.Other

Where did you go to Physical Therapy?

YesNo

When did you stop Physical Therapy?

YesNo

Who is your Chiropractor?

Cervical spineThoracic spineLumbar SpineOther

123

Who did the Epidural steroid injection?

Where was these injections done?

When did you have the injection?

YesNo

RightLeftBilateral

YesNo

How long did the injection help?

When did you have the Facet injection?

YesNo

How long did the Facet injection help?

When did you have the Medial Branch Blcock?

RightLeftBilateral

YesNo

How long did the injection help?

When did you have the Rhizotomy?

RightLeftBilateral

YesNo

How long did the injection help?

When did you have the SI injection?

RightLeftBilateral

YesNo

How long did the injection help?

When did you have the Selective Nerve Root Block?

RightLeftBilateral

YesNo

How long did the injection help?

When did you have the Procedure?

YesNo

How long did the injection help?

YesNo

NeckLower backThoracic areaSI joint

MRICTMyelogram/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?

YesNo

RightLeftBoth

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

Front of legback of leglateral (outside) side of legmedial (inner) side of leg

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)*

SuddenSlowlyDevelopingOther

YesNo

Location of Numbness*

YesNo

Location of Weakness*

ConstantOff and OnOther

BackLower Extremity PainBoth the same

YesNo

RightLeftBoth

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?

More frequentLess frequentNo 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)*

SuddenSlowlyDevelopingOther

YesNo

Location of Numbness*

YesNo

Location of Weakness*

ConstantOff and OnOther

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

YesNo

Numbness of hands and fingersClumsiness of fingers and handsPoor coordination of fingers and handsDifficulty with fine motor skills of handsWeakness of hands and fingers

NeckUpper Extremity PainBoth the same

YesNo

Any other Neurological Complaint Please Explain.

YesNo

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

YesNo

when was the last time that you went to PT?

Yesno

RightLeftBoth

Upper Thoracic Spine on the rightUpper Thoracic Spine on the leftMid Thoracic Spine on the leftMid Thoracic Spine on the rightLower Thoracic Spine on the leftLower Thoracic Spine on the right

RightLeftBoth

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

SuddenSlowlyDevelopingOther

Explain your pain.

ConstantOff and OnOther

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

Pain in Mid backPain that wraps around into the ribsBoth the same

YesNo

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?

YesNo

What treatment if any have you had for this problem?

New Patient History

General Information

Many patients have more than one problem that they would like for us to evaluate and treat. We like to focus on one area before moving to the next area to be treated.

Back Section

Neck Section

Headache Section

Facial Pain Questionaire

Thoracic Spine Section

Neurological Section