New Patient Form

Patient Information

Patient First Name

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Patient Last Name

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Date of Birth

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Today's Date

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Appointment Date

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Choose an office:

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Age

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Hand Dominant

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Occupation

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Weight

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Height

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Primary Care Doctor

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Primary Care Doctor Phone #

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Pain Management Doctor

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Pain Management Doctor Phone #

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Who referred you to us?

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Present Symptoms/Complaints

Describe present symptoms/complaints:

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When did this problem begin?

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Is this a work injury?

Yes

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Motor Vehicle?

Yes

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Injury due to a fall?

Yes

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How did this problem/Injury occur?

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Do you have an Attorney for this injury?

Yes

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If Yes, Who is your Attorney?

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Previous injury to this body part?

Yes

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If Yes, When?

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Does anything make the problem worse?

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Does anything make the problem better?

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Did you bring X-rays and/or MRI with you?

Yes

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If Yes, When?

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Lifestyle

Smoking History

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Current Smoker

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How many packs a day?

Recreational Drugs?

Yes

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What type?

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Alcohol History

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Marital Status

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Living Presently Alone

Yes

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Number of Children

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Past/Present Medical History

Past/Present Medical History: PLEASE CHECK ALL THAT MAY APPLY TO YOU AND WRITE ANY OTHERS

Hypertension (High Blood Pressure)

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Hypotension (Low Blood Pressure)

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A-Fib/Angina Pectoris

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Asthma

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COPD

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Sleep Apnea

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HIV

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AIDs

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Hepatitis A

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Hepatitis B

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Hepatitis C

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Prostate Disorder

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Rheumatoid Arthritis

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Lupus

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Thyroid

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Fibromyalgia

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Esophageal Reflux/Acid Reflux

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Blood Clots/Thrombophlebitis

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GOUT

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Rosacea

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MRSA

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High cholesterol (Hyperlipidemia

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Depression

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Anxiety

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Bipolar

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Schizophrenia

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Epilepsy/Seizure

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Alzheimer's/Dementia

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Heart Attack

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Stroke

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Fallen in past year

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2 or more falls in past year

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NO KNOWN PAST MEDICAL HISTORY

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Other

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Cancer (what kind?)

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Remission

Yes

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Diabetes (what kind?)

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Other

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Past Surgical History/Hospitalization

Past Surgical History/ Hospitalizations: PLEASE CHECK ALL SURGERIES THAT MAY APPLY TO YOU AND WRITE ANY OTHERS

Hysterectomy

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Tubal ligation

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C-Section x

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Cholecystectomy(Gallbladder)

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Appendix removed

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Tonsillectomy

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Adenoidettomy

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Pacemaker

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CABG(Coronary Artery Bypass Graft)

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lnterventional Cardiac Catherization

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NO KNOWN SURGICAL HISTORY/HOSPITALIZATIONS

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Other

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Carpal Tunnel

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Stent Placement (How Many?)

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Total Hip

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Total Knee

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Total Shoulder

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Spinal Surgery (What kind/what level?)

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Hand/Wrist (What Kind)

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Foot/Ankle (What Kind)

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Knee Arthroscopy

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Shoulder Arthroscopy

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Other surgeries (What Kind)

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Family History Father

Father

Cancer

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Heart Disease

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High Blood Pressure

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Kidney Disease

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Liver Disease

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Thyroid

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Diabetes

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Respiratory

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Stroke

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Mental Illness

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Epilepsy /Seizures

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UNKNOWN FAMILY HISTORY

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Family History Mother

Mother

Cancer

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Heart Disease

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High Blood Pressure

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Kidney Disease

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Liver Disease

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Thyroid

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Diabetes

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Respiratory

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Stroke

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Mental Illness

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Epilepsy /Seizures

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UNKNOWN FAMILY HISTORY

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Family History Brother

Brother

Cancer

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Heart Disease

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High Blood Pressure

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Kidney Disease

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Liver Disease

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Thyroid

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Diabetes

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Respiratory

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Stroke

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Mental Illness

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Epilepsy /Seizures

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UNKNOWN FAMILY HISTORY

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Family History Sister

Sister

Cancer

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Heart Disease

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High Blood Pressure

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Kidney Disease

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Liver Disease

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Thyroid

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Diabetes

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Respiratory

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Stroke

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Mental Illness

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Epilepsy /Seizures

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UNKNOWN FAMILY HISTORY

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Family History Son

Son

Cancer

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Heart Disease

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High Blood Pressure

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Kidney Disease

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Liver Disease

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Thyroid

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Diabetes

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Respiratory

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Stroke

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Mental Illness

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Epilepsy /Seizures

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UNKNOWN FAMILY HISTORY

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Family History Daughter

Daughter

Cancer

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Heart Disease

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High Blood Pressure

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Kidney Disease

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Liver Disease

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Thyroid

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Diabetes

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Respiratory

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Stroke

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Mental Illness

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Epilepsy /Seizures

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UNKNOWN FAMILY HISTORY

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Medication/Allergies

Medications You Currently Taking: Name & Dosage (PLEASE INCLUDE VITAMINS)

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No Known Allergies (select the check box below)

No Known Allergies

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Allergies To Any Medication/Food

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Current Symptoms

Constitutional

Recent Weight Change

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Fever/Chills

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Sweating heavily at night

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Feeling poorly

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Eyes/Head

Vision problems

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Blurry Vision

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Vision Prescription

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Headache

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HENT

Loss of hearing

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Ringing in the ears (tinnitus)

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Issues with gums/teeth

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Hoarseness/difficult swallowing

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Respiratory

Difficulty breathing

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Cough

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Shortness of breath

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Coughing up blood

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Digestive

Belching/Bloating/Heartburn

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Nausea/Vomiting

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Diarrhea

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Constipation

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Abdominal Pain

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Heart

Chest pain/discomfort

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Fast heart rate

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Palpitations

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Musculoskeletal

Muscle weakness

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Neck Pain

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Low Back Pain

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Joint Swelling

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Joint Pain

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Nervous System

Fainting

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Convulsions/Seizures

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Tingling

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Numbness

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Dizziness

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Skin

Pruritus

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Skin Lesions

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Rash

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Psoriasis

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Endocrine/Glands

Excessive thirst/fluid intake

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Hot flashes

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Temperature intolerance (Heat/Cold)

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Blood/Lymph

Easy Bleeding

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Easy Bruising

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Swollen Glands in the neck

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Urinary System

Blood in urine

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Painful urination

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Incontinence

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Penile discharge

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Decreased urination

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Female Reproductive

Normal Menstruation

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Menopausal

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Vaginal discharge

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Pelvic pain

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Painful urination

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Sleep Disturbances

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Depression

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Feeling Nervous

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