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Helix Pain Solutions851 Meadows Road. Suite 212. Boca Raton. Florida – 33486Office: 561 392-1979 Fax: 561 392-9707

New Patient Intake Form

Completing this intake form helps our providers get to know you and your medical history. We rely on its accuracy and completeness to provide you with the best care possible. Please take your time and inquire at our front desk or call (561) 392-1979 if you have any questions or are unsure how to complete any section of this form.

Your Name

Date of Birth Age Home Phone Number

Address

City State Zip Code

Mobile Phone Number Carrier

Email Address

Preferred Contact Method ☐ Phone Call ☐ Text Message ☐ E-mail

Pharmacy Telephone Number

Occupation Employer

Work Address

City State Zip Code

Work Phone Number

Emergency Contact Person

Contact Number Relationship

Referring Physician Office Number

Primary Care Physician Office Number

Insurance Carrier Plan

Policy/ID Number Group Number

Subscriber Name Subscriber Date of Birth

Subscriber Social Security Patient Relationship to Subscriber

New Patient Intake Form of 8


Pain AssessmentUse this diagram to indicate the location and type of your pain. Mark areas where pain radiates or spreads. Mark the drawing with the following letters that best describe your symptoms:



What number on the pain scale (0-10) best describes your pain right now?

What number on the pain scale (0-10) best describes your worst pain?

What number on the pain scale (0-10) best describes your least pain?

What number on the pain scale (0-10) best describes your average pain over the last month?

Where is the area of your worst pain?

Does this pain radiate? ☐ Yes ☐ No Where to?

When did your pain begin?

What do you think caused your current pain?

Since your pain began, how has it changed? ☐ Decreased ☐ Increased ☐ Stayed the Same

Describe the frequency of your pain ☐ Constant ☐ Intermittent (Comes and Goes)

When is your pain at its worst? ☐ Morning ☐ During the Day ☐ Evening ☐ Night

Check all of the following that describes your pain:

☐ Aching ☐ Hot/Burning ☐ Shooting ☐ Pressure

☐ Cramping ☐ Numbness ☐ Spasming ☐ Throbbing

☐ Dull ☐ Sharp/Stabbing ☐ Shock-like ☐ Pins and Needles

☐ Squeezing ☐ Tiring/Exhausting ☐ Tingling ☐ Ripping

☐ Knot-Like ☐ Pinching ☐ Other: ☐ Other:

Do you have any of the following symptoms:



☐ Balance Problems ☐ Dizziness ☐ Bladder Incontinence☐ Bowel Incontinence

☐ Fevers ☐ Chills ☐ Nausea ☐ Vomiting

☐ Weakness – Where? ☐ Numbness/Tingling – Where?

Activities That Affect Your Pain Increases Pain Decreases Pain No Change

Bending Backward ☐ ☐ ☐Bending Forward ☐ ☐ ☐Changes in Weather ☐ ☐ ☐Climbing Stairs ☐ ☐ ☐Coughing/Sneezing ☐ ☐ ☐Driving ☐ ☐ ☐Lifting Objects ☐ ☐ ☐Looking Forward ☐ ☐ ☐Looking Downward ☐ ☐ ☐Looking Side to Side ☐ ☐ ☐Rising from a Seated Position ☐ ☐ ☐Sitting ☐ ☐ ☐Standing ☐ ☐ ☐Walking ☐ ☐ ☐

What other factors worsen or affect your pain that is not listed above?

Have you seen other physicians or providers to treat your pain?

☐ Primary Care Physician ☐ Pain Physician ☐ Neurosurgeon ☐ Orthopedic Surgeon

☐ Neurologist ☐ Rheumatologist ☐ Psychiatrist ☐ Psychologist

☐ Sports Physician ☐ Physiatrist ☐ Other: ☐ Other:

☐ Chiropractor ☐ Massage Therapist ☐ Physical Therapist ☐ Acupuncturist

Have you had any diagnostic imaging or tests done for your pain? ☐ Yes ☐ No

MRI of the Date Facility



X-Ray of the Date Facility

CT Scan of the Date Facility

EMG/NCV Test Date

Other

MedicationsPlease list ALL medications, vitamins, and supplements you are taking (use additional paper if needed):

Name Dose Frequency

Are you taking any blood-thinners or aspirin? ☐ Yes ☐ No

If yes, then which blood-thinner are you taking?

Prescribing Physician Office Number

Allergies

Do you have any known drug allergies? ☐ Yes ☐ No

Medication Name Reaction

Topical Allergies: ☐ Iodine ☐ Latex ☐ Tape

Treatment HistoryHave you had any of the following done for your pain?Treatment No Relief Moderate Relief Excellent Relief



☐ Rest ☐ ☐ ☐☐ Biofeedback ☐ ☐ ☐☐ Neck or Back Brace ☐ ☐ ☐☐ Chiropractic Adjustments ☐ ☐ ☐☐ Decompression Therapy ☐ ☐ ☐☐ Home Exercise Program ☐ ☐ ☐☐ Physical Therapy ☐ ☐ ☐

☐Number of Sessions:

☐ Massage ☐ ☐ ☐☐ TENS Unit ☐ ☐ ☐☐ Medial Branch Blocks or Facet Injections ☐ ☐ ☐☐ Epidural Injections ☐ ☐ ☐☐ Other Nerve Blocks ☐ ☐ ☐

☐Where?:

☐ Radiofrequency Ablation ☐ ☐ ☐☐Where?:

☐ Joint Injections ☐ ☐ ☐☐Where?:

☐ Medications, please check which ones below -☐ Topical Cream ☐ ☐ ☐☐ Anti-Inflammatories ☐ ☐ ☐☐ Muscle Relaxants ☐ ☐ ☐☐ Nerve Pain Medications ☐ ☐ ☐☐ Opioids ☐ ☐ ☐☐ Steroids ☐ ☐ ☐☐ Natural Supplements ☐ ☐ ☐

☐ Spinal Cord or Peripheral Nerve Stimulator

☐ Trial ☐ Permanent ☐ ☐ ☐☐ Trigger Point Injections ☐ ☐ ☐☐ Vertebroplasty/Kyphoplasty ☐ ☐ ☐

☐Levels?:

☐ Spine Surgery ☐ ☐ ☐

Social History

Are you capable of becoming pregnant? ☐ Yes ☐ No

If so, then are you currently pregnant? ☐ Yes ☐ No

Highest level of education obtained:



Tobacco Use ☐ Yes ☐ No Packs Per Day

Alcohol Use ☐ Yes ☐ No Drinks Per Week

Caffeine Use ☐ Yes ☐ No Cups Per Day

Recreational Drug Use ☐ Yes ☐ No Times Per Week

Do you exercise? ☐ Yes ☐ No Times Per Week

Type of Exercise:

Activity Level at Work? ☐ Sitting ☐ Standing ☐ Light Labor ☐ Heavy Labor

Overall Stress Level ☐ Low ☐ Medium ☐ High

Review of SystemsMark all of the following symptoms that you CURRENTLY suffer from.

Constitutional☐ Weight Change

☐ Fever

☐ Chills

☐ Rashes

☐ Easy bruising

☐ Pale

HEENT☐ Vision Changes

☐ Hearing Loss

☐ Difficulty Swallowing

Cardiovascular☐ Chest Pain/Pressure

☐ Palpitations

☐ Arm or Leg Swelling

☐ Blood Clots

☐ Arm or Leg Cramping

Genitourinary☐ Frequent Urination

☐ Urinary Urgency

☐ Decreased Libido

☐ Sexual Dysfunction

Respiratory☐ Cough

☐ Shortness of Breath

☐ Wheezing

☐ Bloody Cough

Gastrointestinal☐ Abdominal Pain

☐ Bloody Stools

☐ Changes in Appetite

☐ Nausea

☐ Vomiting

Musculoskeletal☐ Joint pain

☐ Muscle pain

☐ Restricted Motion

Neurological☐ Anxiety/Depression

☐ Suicidal Thoughts

Endocrine☐ Heat Intolerance

☐ Cold Intolerance

☐ Increased Thirst

Medical HistoryMark the following conditions or diseases that you have been treated for in the past.



General Medical☐ Cancer – Type: ☐ Chronic Fatigue☐ FibromyalgiaSleep DisorderHEENT☐ Headaches☐ Migraines☐ Head Injury☐ Glaucoma☐ Facial Pain☐ Dental PainCardiovascular☐ Heart Attack/MI☐ High Blood Pressure☐ High Cholesterol☐ Heart Murmur☐ Heart Valve Disease☐ Stroke☐ Coronary Artery Disease☐ Arrhythmia

Pulmonary☐ Asthma☐ Bronchitis☐ COPD☐ Emphysema☐ TuberculosisGastrointestinal☐ GERD/Reflux☐ Peptic Ulcer Disease☐ Constipation☐ Bowel Incontinence☐ Gastrointestinal Bleeding☐ Hepatitis: Type: ☐ Irritable Bowel Syndrome (IBS)☐ Crohn’s Disease☐ Ulcerative Colitis☐ Chronic Abdominal Pain

Endocrine☐ Diabetes: Type: ☐ Hyperthyroidism☐ HypothyroidismGenitourinary☐ Bladder Infections☐ Urinary Tract Infections☐ Overactive Bladder☐ Kidney Stones☐ Urinary Incontinence☐ Erectile Dysfunction☐ Painful Intercourse☐ Enlarged Prostate/BPH☐ Chronic Pelvic PainHematological☐ Anemia☐ Bleeding Disorder☐ Poor Circulation☐ Varicose Veins☐ Spider Veins

Neurological☐ Substance Abuse☐ Alcohol Abuse☐ Alzheimer’s Disease☐ Dementia☐ Bipolar Disorder☐ Depression☐ Anxiety☐ Schizophrenia☐ Multiple Sclerosis☐ Peripheral Neuropathy☐ Seizures☐ Complex Regional Pain ☐ Syndrome (CRPS)☐ Low back painInfectious

☐ Tuberculosis☐ HIV/AIDS

Other☐ Thyroidectomyfff

Surgical HistoryPlease indicate any surgical procedures you have done in the past, including the date and any pertinent details.

Abdominal Surgery☐ Gallbladder Removal

☐ Appendix Removal

☐ Hernia Repair

Gynecological Surgery☐ Caesarean Section

☐ Hysterectomy

☐ Laparoscopy

Cardiac Surgery☐ Bypass Surgery

☐ Stent Placement

☐ Valve Replacement

Joint Surgery☐ Shoulder

☐ Hip

☐ Knee

☐ Ankle

Spine Surgery☐ Discectomy

☐ Laminectomy

☐ Fusion

Gastric Surgery☐ Lap Band

☐ Gastric Bypass

Miscellaneous☐ Thyroidectomy

☐ Hemorrhoid Removal

☐ Vasectomy

☐ Tonsillectomy

☐ Cosmetic Surgery

☐ Dental Surgery

Other☐ Thyroidectomyffffffff

☐ Hemorrhoid Removal

☐ Vasectomyffffffffffffff

☐ Tonsillectomffffffffffy

Have you or a family member ever had an adverse reaction to anesthesia? ☐ Yes ☐ No


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