New Patient Intake Form
All fields with
*
are required
Date of Birth
Patient Name
Age
SSN #
Height
Weight
Primary Care Doctor
Primary Care Doctor's Phone
Primary Care Doctor's Fax
Referring Doctor
Referring Doctor's Phone
Referring Doctor's Fax
Case Manager (If applicable - otherwise skip to next section)
Case Manager's Phone
Case Manager's Fax
Attorney's Name (If applicable)
Attorney's Phone
Attorney's Fax
Where does your pain originate from?
example: right shoulder, mid lower back, below my right kneecap
Does your pain radiate to another area? If so, tell us where
example: right shoulder, mid lower back, below my right kneecap
When and how did your painful condition begin?
Check the words that best describe your pain (any that apply)
Aching
Throbbing
Sharp
Stabbing
Shooting
Gnawing
Tender
Burning
Tiring
Penetrating
Nagging
Numb
Unbearable
Constant
Intermittent
Cramping
Shock Like
Dull
Does your pain occur occasionally, frequently or is it constant? (Choose one)
Occasionally
Frequently
Constantly
What time of day is your pain the worst? (Choose one)
Morning
Afternoon
Evening
Night time
Rate your pain by circling the number that best describes the LEAST pain you have felt in the last month
0 = No Pain 10 = Worst Pain Imaginable
0
1
2
3
4
5
6
7
8
9
10
Rate your pain by circling the number that best describes the AVERAGE pain you have felt in the last month
0 = No Pain 10 = Worst Pain Imaginable
0
1
2
3
4
5
6
7
8
9
10
Rate your pain by circling the number that best describes your pain right now
0 = No Pain 10 = Worst Pain Imaginable
0
1
2
3
4
5
6
7
8
9
10
Please list anything that makes your pain feel better
Please list anything that makes your pain feel worse
How many hours do you sleep each night?
0
1
2
3
4
5
6
7
8
9
10
11
12+
How has your mood been during the last few months?
Please list any other medical conditions that affect you
Please list any injections or surgeries you have had to relieve your pain
What medications do you take? (Please include dosage and frequency)
What other medications have you tried in the past to relieve your pain?
Please list any medications you are allergic to (Include the specific reaction you experienced)
Do you take blood thinners?
Yes
No
Have you ever had a bad reaction to radiologic contrast dye?
Yes
No
Do you smoke?
Yes
No
How many cigarette's per day?
N/A
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
25
30
40+
Do you drink alcohol?
Yes
No
How many units per day?
N/A
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
25
30
40+
Do you use any other illegal drugs not prescribed by a physician?
Yes
No
What is your current occupation?
Are you on disability leave currently?
Yes
No
Do you have any current or old workers compensation cases?
Yes
No
If yes, please include information about the injured body part, date of injury, and your case managers information
Do you have a family history of chronic pain?
Yes
No
Have you ever been dismissed from a doctors office?
Yes
No
If yes, please include the reason
Are there any pending lawsuits or do you have an attorney associated with your pain?
Yes
No
Please include any other information we should know to help manage your pain
Drug Abuse Diversion: We are passionate about and dedicated to helping our patients overcome their pain. We expect patients to be committed to working with us in order to get better. We will do everything we can to help our patients but we are strongly opposed to any type of drug abuse and diversion. We work hard to eliminate this possibility from our practice and wherever we discover such conduct in violation of law we will not hesitate to alert law enforcement.
I attest that I have read and understood the above drug abuse diversion policy and will abide by its rules
Clear
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