New Patient Intake Form

Patient Name: E-mail

Birthday: Age Sex: Male/Female

Referring Physician

Family Physician

Other Health Care Providers Involved with Your Care:

Neurosurgeon Orthopedic Surgeon

Pain Management Specialist Psychologist/Psychiatrist

Physical Therapist Chiropractor

Other

1. Chief Complaint-What is the reason for your visit to our office

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2. Onset -When did the pain or the concern(s) starts?Was the start of the pain or concern?

suddengradual

3. Cause of Pain-What started your pain?

Work related accident or event?

yesno

If yes, date

Is this under Workers Compensation?

yesno

If yes, Case #

Motor vehicle accident

yesno

If yes, date

Unknown

yesno

If yes, date

Other (briefly explain)

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4. Location-Where are your symptoms? Shade the areas where you pain or concern Circle the areas where you have numbness/tingling XXX the areas where you have weakness

NOTE: If you are being seen for Neck pain, answer questions 5-12 and skip questions 13-20. If you are being seen for Back pain, skip questions 5-12 and answer questions 13-20.

Neck Pain History (questions 5-12)

5. Quality--Which of the following describes your Neck pain? Check all Boxes that apply

Aching Agonizing Annoying BurningCold Constricting Cramping DeepDisabling Dull Exhausting FearfulHeavy Horrible Hot ItchingNagging Numb Pressure PulsatingSharp Shooting Sickening StabbingSuperficial Tender Throbbing TinglingTiring Toothache-like Uncomfortable WeakeningOther

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6. Quality--Which of the following describes your Arm pain? Check all Boxes that apply If the same symptoms are present as in Neck pain? (If yes, then go to questions 7) It's Different than the neck pain (Circle all that apply)

I have symptoms in: Right Arm Left Arm Both Arms

Aching Agonizing Annoying BurningCold Constricting Cramping DeepDisabling Dull Exhausting FearfulHeavy Horrible Hot ItchingNagging Numb Pressure PulsatingSharp Shooting Sickening StabbingSuperficial Tender Throbbing TinglingTiring Toothache-like Uncomfortable WeakeningOther

Pain Scale Rating: 0 = no pain, 10 = as bad as it gets

7. Please rate your Neck pain

0 1 2 3 4 5 6 7 8 9 10

At its worse

At its best

Now

Average

8a. Please rate your Right Arm pain

If the same symptoms are present as in Neck pain? (If yes, then go to questions 7) It's Different than the neck pain (Shade all that apply)

0 1 2 3 4 5 6 7 8 9 10

At its worse

At its best

Now

Average

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Does the pain, numbness or tingling radiate down the Left Arm? Shoulder Elbow Wrist Fingers

8b Please rate your Left Arm pain

If the same symptoms are present as in Neck pain? (If yes, then go to questions 7) It's Different than the neck pain (Shade all that apply)

0 1 2 3 4 5 6 7 8 9 10

At its worse

At its best

Now

Average

9. Better --- What makes your Neck pain better

Acupuncture Activity AlcoholApplying Pressure Bending Changing PositionChiropractic care Exercise Cold/IceHeat Lying Down MedicationMassage Nerve Blocks NothingPhysical Therapy Relaxation Therapy RestSitting Sleeping StandingStretching TENS Unit Using a BraceWarm Bath/Shower WalkingOther

10. Better --- What makes your Arm pain better

If the same symptoms are present as in Neck pain? (If yes, then go to questions 11 ) It's Different than the neck pain (fill in the blanks below)

Acupuncture Activity AlcoholApplying Pressure Bending Changing PositionChiropractic care Exercise Cold/IceHeat Lying Down MedicationMassage Nerve Blocks NothingPhysical Therapy Relaxation Therapy RestSitting Sleeping StandingStretching TENS Unit Using a BraceWarm Bath/Shower WalkingOther

5

Does the pain, numbness or tingling radiate down the Left Arm? Shoulder Elbow Wrist Fingers

11. Worse --- What makes your Neck pain worse (x on all that apply)

Activity Bending Bowel MovementsClimbing Stairs Coughing ExerciseLifting Lying Down MotionNerve Blocks Nothing Physical TherapyPulling Pushing SexSitting Sleeping SneezingSquatting Standing StressStretching Stooping Surgery Made it WorseTwisting Using a Brace WalkingWeather Changes Other

12. Worse --- What makes your Arm pain worse (x on all that apply)

If the same symptoms are present as in Neck pain? (If yes, then go to questions 21) It's Different than the Neck pain (fill in the blanks below)

Activity Bending Bowel MovementsClimbing Stairs Coughing ExerciseLifting Lying Down MotionNerve Blocks Nothing Physical TherapyPulling Pushing SexSitting Sleeping SneezingSquatting Standing StressStretching Stooping Surgery Made it WorseTwisting Using a Brace WalkingWeather Changes Other

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Back Pain History (questions 13-20)

13. Quality--Which of the following describes your Back pain? Check all Boxes that apply

Aching Agonizing Annoying BurningCold Constricting Cramping DeepDisabling Dull Exhausting FearfulHeavy Horrible Hot ItchingNagging Numb Pressure PulsatingSharp Shooting Sickening StabbingSuperficial Tender Throbbing TinglingTiring Toothache-like Uncomfortable WeakeningOther

14. Quality--Which of the following describes your Leg pain? Check all Boxes that applyIf the same symptoms are present as in Back pain? (If yes, then go to questions 15)It's Different than the back pain (Circle all that apply)

I have symptoms in: Right Leg Left Leg Both Legs

Aching Agonizing Annoying BurningCold Constricting Cramping DeepDisabling Dull Exhausting FearfulHeavy Horrible Hot ItchingNagging Numb Pressure PulsatingSharp Shooting Sickening StabbingSuperficial Tender Throbbing TinglingTiring Toothache-like Uncomfortable WeakeningOther

Pain Scale Rating: 0 = no pain, 10 = as bad as it gets

15. Please rate your Back pain

0 1 2 3 4 5 6 7 8 9 10

At its worse

At its best

Now

Average

7

16a. Please rate your Right Leg pain

If the same symptoms are present as in Back pain? (If yes, then go to questions 17) It's Different than the back pain (Shade all that apply)

0 1 2 3 4 5 6 7 8 9 10

At its worse

At its best

Now

Average

Does the pain, numbness or tingling radiate down the Right leg? Hip Buttock Thigh Knee Lower Leg Foot Toes

16b. Please rate your Left Leg pain

If the same symptoms are present as in Back pain? (If yes, then go to questions 17) It's Different than the back pain (Shade all that apply)

0 1 2 3 4 5 6 7 8 9 10

At its worse

At its best

Now

Average

17. Better --- What makes your Back pain better

Acupuncture Activity AlcoholApplying Pressure Bending Changing PositionChiropractic care Exercise Cold/IceHeat Lying Down MedicationMassage Nerve Blocks NothingPhysical Therapy Relaxation Therapy RestSitting Sleeping StandingStretching TENS Unit Using a BraceWarm Bath/Shower WalkingOther

8

Does the pain, numbness or tingling radiate down the Left leg? Hip Buttock Thigh Knee Lower Leg Foot Toes

18. Better --- What makes your Leg pain better

If the same symptoms are present as in Back pain? (If yes, then go to questions 11 ) It's Different than the back pain (fill in the blanks below)

Acupuncture Activity AlcoholApplying Pressure Bending Changing PositionChiropractic care Exercise Cold/IceHeat Lying Down MedicationMassage Nerve Blocks NothingPhysical Therapy Relaxation Therapy RestSitting Sleeping StandingStretching TENS Unit Using a BraceWarm Bath/Shower WalkingOther

19. Worse --- What makes your Back pain worse (x on all that apply)

Activity Bending Bowel MovementsClimbing Stairs Coughing ExerciseLifting Lying Down MotionNerve Blocks Nothing Physical TherapyPulling Pushing SexSitting Sleeping SneezingSquatting Standing StressStretching Stooping Surgery Made it WorseTwisting Using a Brace WalkingWeather Changes Other

9

20. Worse --- What makes your Leg pain worse (x on all that apply)

If the same symptoms are present as in Back pain? (If yes, then go to questions 21) It's Different than the Back pain (fill in the blanks below)

Activity Bending Bowel MovementsClimbing Stairs Coughing ExerciseLifting Lying Down MotionNerve Blocks Nothing Physical TherapyPulling Pushing SexSitting Sleeping SneezingSquatting Standing StressStretching Stooping Surgery Made it WorseTwisting Using a Brace WalkingWeather Changes Other

21. Prevalence --- How often do you have pain? (x on all that apply)

Rarely IntermittentlyNot Daily Some DailyMost of the time Daily Constant with VariationConstant with No Change

22. Progression --- How is your pain changing? (x on all that apply)

Getting Better Getting WorseNo Change Since Pain Started

23. Sleeping ---- How has your sleep changed due to pain? (x on all that apply)

No difficulty with sleep

Difficulty falling sleep:

occasionallyfrequentlynightly

Difficulty staying asleep

occasionallyfrequentlynightly

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24. Testing --- What testing have you had RECENTLY? (x on all that apply)

Biopsy Bone ScanCT Scan DEXA ScanDiscogram EMG/Nerve Conduction TestFunctional Capacity Test MRIMyelogram Nerve BlocksPain Injections Spinal TapX-RaysOther

25. Treatment ---- What treatments have you had to resolve your issue? (x on all that apply)

Aerobic ExerciseBiofeedbackChiropractor ManipulationHypnotherapyMassage TherapyPain MedicationPool ExerciseRelaxation TherapySteroid PillsTENS Unit

BedrestBracing Cryoanalgesia Morphine Pump NonePhysical Therapy Radiofrequency Spinal Cord Stimulator Therapeutic Injections TractionPain InjectionsWork Modification

Other

26. Medical History (x on all that apply)

HEENT Cataracts BlindnessDeafness Hearing AidsEnvironmental AllergiesOther

Respiratory: Asthma Chronic BronchitisCOPD EmphysemaSarcoidosis Pulmonary EmbolusSleep Apnea CPAP/BIPAP useOther

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Specify all of your therapies that were attempted along with length or period of time that you tried them.

Cardiovascular Heart Disease High Blood PressureHigh Cholesterol Heart AttackDVT(blood clot) PacemakerDefibrillator Heart ArrhythmiaHeart Failure (CHF) Heart MurmurOther

Gastrointestinal Crohn's Disease GERD/ Acid RefluxHepatitis Liver DiseasePeptic Ulcer Disease Irritable BowelOther

Urinary Kidney Disease Kidney Stones Kidney TransplantOther

OB/GYN: ( women only) Post -Menopausal for how many years

Orthopedic Osteoarthritis ScoliosisJoint Surgeries Other

Rheumatologic: Ankylosis Spondylolitis FibromyalgiaGout LupusOsteoarthritis Rheumatoid ArthritisOther

Neurologic Alzheimer's Brain TumorClosed Head Injury StrokeChiari Malformation Multiple SclerosisMigraine ParalysisDiabetic Neuropathy Guillan-BarreSeizure EpilepsyOther

Psychiatric Anxiety Bipolar DepressionOther

Endocrine Diabetes Hyperthyroid HypothyroidOsteopenia OsteoporosisOther

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Hematologic AnemiaProlonged BleedingHemophiliaOther

Infectious HIV/AIDS Tuberculosis Hepatitis BHepatitis C MRSA InfectionOther

Surgery Problems

Trouble Awakening Post Op Nausea/ VomitingSuture ReactionOther

Cancer: Where/Type

27. Past Spine Problems/ Injuries/ Surgeries

Type of Problem/ Surgery Treating Physician/Surgeon Date of Occurence

28. Surgical History- list of all the other surgeries you have had in the past:

Date Surgery Type

29. Social History

I am : Right Handed Left Handed Ambidextrous

Tobacco: NonsmokerSmoker

Packs per day

13

Quit Smoking X Years Ago Years of Smoking

Alcohol: Drinks per

week on average

none 1-23-6 7-1415+ Choice 1Other

Prescription Drug History

No history of abuse/addictionHistory of abuse/addictionCurrently addicted to pain medicationOther

Illegal Drug History

No History of drug abuse/addictionHistory of abuse/addictionCurrently addicted to illegal drugsOther

30. Family History (mark all that apply)

Father Mother Child Grand- Sister or Brother

Other

Alcoholism

Back/Neck Problems

Chronic Pain

Diabetes

Drug Addiction

Heart Disease

Kidney Disease

Rheumatoid Arthritis

Cancer (List Kind)

Other

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Other_____________________________________________________________________________________

parent

31. Medications

Name of Medication Dose/ Frequency Reason for Taking?

32. Allergies

Name of medication or source What reaction does it cause?

Review of Symptoms (x all that apply)

General Weight Loss Weight Gain FatigueFever Chills Night SweatsWeaknessOther

Head Trauma Headache ConcussionOther

Eyes Vision Loss Blurriness GlaucomaGlasses Contact Lenses Cataract SurgeryOther

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Ears Hearing Loss Ringing in the earsDizziness EaracheHearing AidsOther

Nose Chronic Nasal Congestion NosebleedsSnoringOther

Throat/Neck Bleeding Gums HoarsenessSore Throat Difficulty SwallowingSwollen Neck Neck Lumps/MassesOther

Respiratory Shortness of Breath WheezingOxygen usageOther

Cardiovascular Palpitations Chest PainLeg Swelling Leg Pain while WalkingOther

Gastrointestinal Loss of Appetite NauseaVomiting IndigestionConstipation DiarrheaBloody Stools Black/Tarry StoolsAbdominal Pain Inability to control bowelsOther

Urinary Difficulty Emptying Bladder Sexual DysfunctionInability to Control BladderOther

Bone & Joint Joint Stiffness Achy JointsSwelling Joints Redness of JointsDaytime Muscle CrampsOther

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Neurological Muscle Weakness Tremors FaintingBlackouts Loss of BalanceMemory ProblemsChoice 2Other

Psychiatric Changes in Mood Changes in Stress/TensionAnxiousness SadnessThoughts of Suicide Panic AttacksOther

Signature

Completing this questionnaire will help us to serve you substantially better. Be sure to bring this with you to your appointment. Please bring all insurance information. Bring the CDs of your imaging studies! Bring all of your reports as well. Thank You!

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