New Patient Intake Form | Comprehensive Spine & Sports Center

1 Personal Information

First Name *

Middle Name

Last Name *

Date of Birth *

Age

Gender *

Marital Status

Spouse Name (if married)

Street Address *

City *

State *

ZIP Code *

Phone Number *

Cell Phone

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Relationship to You *

Medical Information Sharing

Share medical info with another person if unavailable?

Yes No

Person's Name

Relationship

2 Employment Information

Occupation

Employer

Retired

Employer Street Address

Employer City

Employer State

Employer ZIP Code

Work Phone

Last Day Worked

3 How Did You Hear About Us?

Referral Source

Referring Physician

Physician Name

Address

City

State

ZIP Code

Phone

Primary Care Physician

Physician Name

Address

City

State

ZIP Code

Phone

4 Insurance Information

Primary Insurance

Insurance Company *

Effective Date

ID/Policy Number *

Group Number

Provided Through

Cardholder Name *

Cardholder Date of Birth *

Secondary Insurance (if applicable)

Insurance Company

Effective Date

ID/Policy Number

Group Number

Provided Through

Cardholder Name

Cardholder Date of Birth

5 Injury Information

Work-Related Injury

Is this a work-related injury?

Yes No

Date of Injury

Last Day of Work

Employer When Injured

Auto-Related Injury

Is this an auto-related injury?

Yes No

Date of Injury

Last Day of Work

Other Injury

Is this another type of injury?

Yes No

Date of Injury

Last Day of Work

Where Did Injury Take Place?

How Were You Injured?

Claim Details (if applicable)

Claim Number

Insurance Company

Caseworker Information

Caseworker Name

Caseworker Phone

Caseworker Address

City

State

ZIP Code

Adjuster Information

Adjuster Name

Adjuster Phone

Legal Representation

Lawsuit Involved?

Yes No

Do You Have an Attorney?

Yes No

Attorney Name

Attorney Phone

Attorney Address

City

State

ZIP Code

6 Chief Complaint & Pain Information

What brings you here today? Please describe your main concern. *

Reason for Visit

Pain Location

Current Pain Level (0-10) *

When did pain start?

What were you doing when it started?

Did it occur:

Suddenly Gradually

Where is pain worse?

Pain Pattern:

Constant Intermittent

Time of Day Pain is Worse

Duration

Type of Pain (check all that apply):

Aching Sharp Throbbing Burning Tingling Dull

Does pain radiate?

Yes No

If yes, describe path:

What Makes Pain Better?

Other (please describe):

What Makes Pain Worse?

Exercise Walking Bending Forward Sitting Coughing Sneezing Bending Backward Standing Lying Down

Other (please describe):

How Does Pain Limit Your Activities?

Need to rest during the day?

Yes No

Additional Symptoms

Numbness?

Yes No

Where?

Weakness?

Yes No

Where?

Bowel function problems

Bladder function problems

Sexual function problems

7 Previous Treatments

Please tell us about any previous treatments you've received for this condition:

Physical Therapy

When?

How Often?

How Many Sessions?

Chiropractic Care

When?

How Often?

How Many Sessions?

Injections

When?

How Often?

How Many?

Other Treatment

When?

How Often?

How Many Sessions?

8 Medical History

Current Medical Conditions

Please check all conditions that apply to you:

Other Conditions (please specify)

Tests Done

MRI Date:

CT Scan Date:

X-Ray Date:

Other Date:

Major Medical Illnesses

Heart Attack Heart Disease Stroke Cancer High or Low Blood Pressure

Other Major Illnesses (please specify)

Hospitalizations

Please list any past hospitalizations or surgeries:

Hospitalization #1

Hospital/Physician

Date/Year

Reason for Admission

Hospitalization #2

Hospital/Physician

Date/Year

Reason for Admission

Hospitalization #3

Hospital/Physician

Date/Year

Reason for Admission

Problems with transfusions/anesthesia?

Yes No

If yes, explain:

Serious Injuries Sustained

9 Allergies & Sensitivities

Claustrophobic/panicky in tight spaces?

Yes No

Metal in body?

Yes No

If yes, what/where?

Medication allergies?

Yes No

Which medications?

Latex allergy?

Yes No

Other allergies?

Yes No

Specify allergies:

10 Current Medications

List all current medications (include dosage)

11 Personal, Social & Family History

Diet & Activity

Special Diet

Regular Exercise

Sports/Athletic Activity

Hobbies/Leisure Activities

Weight & Physical

Current Weight (lbs)

Weight 1 Year Ago (lbs)

Height

Handedness

Tobacco Use

Do you smoke cigarettes?

Yes No

Cigarettes per day

Other tobacco use?

Yes No

Times per day

Alcohol Use

Do you drink alcohol?

Yes No

Type

Amount per day

Street Drugs

Ever used street drugs?

Yes No

Still using?

Yes No

What drugs?

Method

How often?

Other Information

Religious beliefs affecting healthcare?

Emotional health status

Genetic illness in family?

Yes No

What illness?

Family Health History

Please provide information about your immediate family members' health:

Mother

Age (if living)

Health Problems

Age at Death

Cause of Death

Father

Age (if living)

Health Problems

Age at Death

Cause of Death

Grandparents

Age (if living)

Health Problems

Age at Death

Cause of Death

Sister(s)

Age (if living)

Health Problems

Age at Death

Cause of Death

Brother(s)

Age (if living)

Health Problems

Age at Death

Cause of Death

12 Review of Systems

Please check only those symptoms that pertain to you now or in the past:

Head & Neck

Frequent Headaches Migraine Head Injury Dizziness/Fainting

Eyes

Impaired Eyesight Double Vision Blurred Vision Spots Flashing Lights Cataracts

Neck

Swollen Glands Goiter Pain/Stiffness

Ears

Hearing Difficulty Ringing/Buzzing Earaches Discharge Hearing Aid

Nose/Sinus

Frequent Colds Nasal Stuffiness Nose Bleeds Sinus Problems

Mouth/Throat

Bleeding Gums Frequent Sore Throat Hoarseness

Breasts

Nipple Discharge Lumps

Respiratory

Cough up Phlegm Blood in Sputum Shortness of Breath Bronchitis Emphysema Tuberculosis

Cardiovascular

Irregular Heartbeat Racing Heart Heart Murmur Chest Pain Palpitations Cold Feet Swollen Feet/Ankles

Gastrointestinal

Urinary

Frequent Urination Burning on Urination Urgency Bloody Urine Passage of Stones Dribbling

Genital - Male

Discharge from Penis HIV Testicular Swelling Hernias

Genital - Female

Irregular Menses Painful Menses Post-Menopausal Bleeding Uses Birth Control

Musculoskeletal

Aching Muscles/Joints Swollen Joints Muscle Weakness Fibromyalgia

Skin

Itching/Scaling Rashes

Endocrine

Weight Changes Impotence Always Feel Hot Always Feel Cold Drink a Lot of Fluids Change in Size of Gloves/Shoes

Nervous System

Weakness Numbness Seizures Speech Impairment Shaking Change in Handwriting Difficulty Walking

Psychiatric

Depression Suicidal Ideas Trouble Sleeping Panic Attacks Nervousness Memory Impairment

13 Bournemouth BACK Pain Questionnaire

Please answer ALL questions based on the past week, marking the ONE number on EACH scale that best describes how you feel.

1. On average, how would you rate your BACK pain? (0 = no pain, 10 = worst pain) *

2. How much has your BACK pain interfered with your daily activities (housework, washing, dressing, walking, climbing stairs)? (0 = no interference, 10 = unable to do activities) *

3. How much has your BACK pain interfered with social and recreational activities? (0 = no interference, 10 = unable to do activities) *

4. How anxious (tense, uptight, irritable, difficulty concentrating/relaxing) have you been feeling? (0 = not anxious, 10 = extremely anxious) *

5. How depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling? (0 = not depressed, 10 = extremely depressed) *

6. How have you felt your work (both inside and outside the home) has affected (or would affect) your BACK pain? (0 = made it no worse, 10 = made it much worse) *

7. How much have you been able to control (reduce/help) your BACK pain on your own? (0 = complete control, 10 = no control) *

Additional Comments About Your Back Pain

14 Bournemouth NECK Pain Questionnaire

Please answer ALL questions based on the past week, marking the ONE number on EACH scale that best describes how you feel.

1. On average, how would you rate your NECK pain? (0 = no pain, 10 = worst pain) *

2. How much has your NECK pain interfered with your daily activities (housework, washing, dressing, walking, climbing stairs)? (0 = no interference, 10 = unable to do activities) *

3. How much has your NECK pain interfered with social and recreational activities? (0 = no interference, 10 = unable to do activities) *

4. How anxious (tense, uptight, irritable, difficulty concentrating/relaxing) have you been feeling? (0 = not anxious, 10 = extremely anxious) *

5. How depressed (down-in-the-dumps, sad, in low spirits, pessimistic, unhappy) have you been feeling? (0 = not depressed, 10 = extremely depressed) *

6. How have you felt your work (both inside and outside the home) has affected (or would affect) your NECK pain? (0 = made it no worse, 10 = made it much worse) *

7. How much have you been able to control (reduce/help) your NECK pain on your own? (0 = complete control, 10 = no control) *

Additional Comments About Your Neck Pain

15 Consent & Signature

I acknowledge and agree to the above privacy notice and consent to treatment *

Signature (type your full name) *

Date *