Patient Intake Form

**To your first visit, please bring your health insurance card, medication card, photo identification and a list of all medications. Thank you**

Primary Method of CommunicationEmailTextPhoneFacebook

Do you want to access your medical records electronically? Yes No

Do you take any blood thinners (ie: aspirin, clopidogrel (Plavix), warfarin (Coumadin), etc)? Yes No

Who prescribes this & office phone number

How long have you had this pain?

Did one event cause the pain? Yes No

Date of accident/injury, if applicable

Any lawsuits/liability claims related to accident/injury? Yes No

Do you have a lawyer? Yes No

Quality of Pain: Aching Burning Sharp Dull Shooting Throbbing Pins and Needles Non-Descriptive

Is the pain Constant or Intermittent?

Location of pain: Please click or tap on the image and then enter a brief description of the pain.*

If you need to demonstrate more about the pain, enter it here.

Neurological Changes:

Weakness:

Numbness:

Other:

Frequent Stumbling? Yes No

Frequent Falls? Yes No

Since pain began, is it Better, Worse, or Same?

What makes the pain worse? Lying Down Travel Sitting Straightening Up Shooting Lifting Bending Walking Cough/Sneeze Turning Mental Stress Standing Twisting Any Activity

Do you hurt more in the Morning or Night or are they Equal?

What is your pain score (0-10):

Does pain prevent you from falling asleep? Yes No

Do you have trouble sleeping? Yes No

Total number of hours sleep per night

Do you awaken frequently at night? Yes No

Years of Education Completed: <5 years 6-9 years 10-12 years >12 years

Have you tried any of the following medications? Please list. Enter No, if you have not tried any of them.*

NSAIDs (i.e.: ibuprofen, meloxicam)

Benzodiazepines (i.e.: Xanax, valium)

Lyrica (pregabalin) or Neurontin (gabapentin)

Have you tried any of the following? If so, please list when, how long treatment was tried, & if it was helpful.

Injections/Interventions/Procedures

Have you been seen by another pain physician? Yes No

Have you had any of the following tests? If so, please list approximate date & facility where done. List what area of the body this was done on (ie: neck, low back).

EMG/NCV (electromyography/nerve conduction)

Do you have or have you ever had any of the following:

Asthma COPD

Do you use oxygen? Yes No

Bleeding Problem or Blood Disorder

Endocrine Disorder

Diabetes Type 1 Type 2

Do you use insulin? Yes No

Thyroid Low High

Heart Problems

Valve Disease Coronary Artery Disease High Blood Pressure Heart Attack Congestive Heart Failure

Neurological Disorder

Seizure Stroke (CVA) Mini – Stroke (TIA)

Liver Problems Cirrhosis Hepatitis

If Hepatitis C, have you received treatment?

Do you have or have you ever had any of the following:

Is your Mother still living? Yes No

Is your Father still living? Yes No

Please list medical history for the following

Do you experience any of the following?

Shortness of Breath (with or without activity) Shortness of breath when lying down Rectal Bleeding Fainting Frequent Urination Sleep Apnea Cough Abdominal Pain Paralysis Numbness/Tingling Urinary Hesitancy Snoring Chest Pain Nausea and/or Vomiting Muscle Weakness Painful Urination Sexual Dysfunction Other

Do you have any physical limitations?

Do you have any language barriers?

Have you had any recent unexplained weight loss? Yes No

WOMEN:

Are you pregnant? Yes No

Social History:

Alcohol Use Yes No

Tobacco Use/Cigarettes/Chew/Pipe Yes No

Do you use a vapor pen/electronic cigarette? Yes No

With Nicotine Yes No

Present or past (circle one) history of substance abuse? Yes No

Do you live in an abusive environment (for any signs of abuse, we are required to notify social services) Yes No

Are you on disability? Yes No