NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE

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1 NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE DEMOGRAPHICS- To be completed by all patients Patient Name: Today s Date: / / Patient Address: _ City: State: Zip: Home Phone #: ( ) - Work #: ( ) - Cell #: ( ) - Preferred Preferred Preferred Date of Birth: / / SSN: Marital Status: Gender: Male Female Preferred Language: Ethnicity: Hispanic or Latino Not Hispanic or Latino Refuse to Report Race: American Indian, Alaska Native Asian African American White Hispanic Other Pacific Islander Other Race Refuse to Report * Address: HEALTH INSURANCE COVERAGE- To be completed by all patients. (In the case of Workers Compensation, this information will only be used if your compensation is denied). Health Insurance Company Name: Address: City: State: Zip Code: Phone #: ( ) - Insured s Name: Relationship to Patient: Insured s Date of Birth: / / Insured s Employer: ID #: Insured s Social Security #: Group #: Medicare ID #: Do you have secondary insurance? Yes No Carrier Name: ID#: My Visit is NOT related to an accident (Please Initial): NO FAULT/LIABILITY- Please complete this section is your illness/injury is the result of an accident (auto or otherwise- but NOT related). Insurance Company Name: Date of Accident: Address: City: State: Zip Code: Policy #: Claim #: Claims Adjuster: Phone #: ( ) - Location of Accident (State): WORKERS COMPENSATION- Please complete this section if your illness/injury is work related. Insurance Company Name: Date of Accident: Address: City: State: Zip Code: Claim #: Claims Adjuster: Phone #: ( ) - WCB Case #: Employer at the time of the accident: Address: City: State: Zip Code: Contact Person: Phone #: ( ) - Patient s usual work activities on date of illness/injury? Native Hawaiian Page 1 of 7

2 NEW PATIENT QUESTIONNAIRE CONTINUED DISABILITY- To be completed by all patients Are you, or have you been disabled? YES NO Date: Are you out of work? YES NO Are you partially or totally disabled? Name of physician who placed you on disability: Are you receiving disability payments? YES NO If yes, for how long? Are you currently involved in a lawsuit? YES NO If yes, please explain below: Attorney Name: Phone #: ( ) - Address: City: State: Zip Code: EMPLOYMENT- To be completed by all patients. Are You Currently Employed: YES- FULL TIME YES- PART-TIME NO RETIRED Patient s Employer: Employer Phone #: ( ) - Patient s Employer s Address: Occupation: PHYSICIANS- Please list all of your providers. If you do not have a particular physician, enter N/A. Primary Care Provider: Referring Provider: Cardiologist: Neurologist: Pulmonologist: Endocrinologist: Other: ADVANCE DIRECTIVE- To be completed by all patients Do you have an Advance Directive? YES NO Please check any documents that apply Power of Attorney (POA) Living Will (LW) Do Not Resuscitate (DNR) Page 2 of 7

3 NEW PATIENT QUESTIONNAIRE CONTINUED TELL US ABOUT YOUR PAIN Chief Complaint (reason for visit): Referring Provider: Side: Right Left Both On the diagram, shade in the areas where you feel pain: L R R L L R Do you experience: numbness weakness tingling pins/needles burning swelling Approximately when did your symptoms begin? The onset of your pain was: Accident at work Accident other than work (i.e. home, auto) Following illness Following surgery Pain just started- no obvious cause Other What do you believe is causing these symptoms? Your pain occurs: Intermittently Continuously Occasionally Rarely Describe your pain: Throbbing Dull Aching Shooting Stabbing Burning PAIN SCORES- Please answer each question with the appropriate number for your pain (0=NO PAIN, 10=WORST IMAGINABLE PAIN) What number is your current pain? What number is your average pain score over the course of a day? What number represents your worst pain? What number represents your least pain? What activities increase your symptoms? Sitting Walking Cold/damp weather Standing Bending backward Bending forward Lifting Driving What activities decrease your symptoms? Avoiding Sitting Walking Stretching strenuous Rest Standing Ice Heat activity Coughing/ Sneezing Swimming Other: Other: What activity would you like to be able to do? Previous conservative measures: Physical therapy Home exercise program Activity modification Chiropractic treatment Acupuncture Massage TENS therapy Cortisone injections Surgical intervention Other: Bracing Aquatic therapy Biofeedback/relaxation Page 3 of 7

4 NEW PATIENT HISTORY MEDICATION HISTORY- Please list all medications that you take on a daily basis. This includes any herbal supplements or vitamins. Medication Dose Medication Dose PHARMACY- Please list your current pharmacy Name: City: MEDICAL HISTORY- Please check any of the following conditions you have or have had Heart disease Heart attack Irregular heart beat High blood pressure Pacemaker, defibrillator, stents Heart surgery Heart murmur Bronchitis Cancer (Specify ) Sleep apnea COPD Asthma Hepatitis Specify ) Arthritis Rheumatoid arthritis Kidney disease Lupus Stroke Vascular disease TIA Seizures Infection (Specify ) HIV/AIDS Psychiatric problems (Specify ) Depression Anxiety Drug/Alcohol Addiction Misuse of prescription drugs Diabetes TMJ Thyroid disease Blood clots Seizures Pinched nerves Neurologic disorders Fracture Migraines Stomach Ulcers Stomach problems (Specify ) Liver disease Other: Page 4 of 7

5 NEW PATIENT HISTORY CONTINUED ALLERGIES- Please list any food or drug allergies. If you do not have any known allergies, enter None. FALL RISK- To be completed by all patients Have you fallen in the past 1 year? YES NO If yes, how many falls? 1 = 2 3 or more falls Were you injured during any of the falls? YES NO Do you feel unsteady when walking? YES NO NOT APPLICABLE (N/A) Do you worry about falling? YES NO NOT APPLICABLE (N/A) Please circle Not Applicable if you Use Wheelchair for Mobility or are Unable to Walk DEPRESSION- To be completed by all patients Over the last 2 weeks, how often have you been bothered by any of the following problems? Not At All Several days More than Half the Days Nearly Every Day Little interest or pleasure in doing things Feeling down, depressed, or hopeless Are you currently being treated for a diagnosis of depression? YES NO SURGICAL HISTORY- Please list all surgeries you have had, including injection therapy. Surgery Date Surgery Date FAMILY HISTORY- Please list all medical conditions that are present in your family. None Unknown Page 5 of 7

6 NEW PATIENT QUESTIONNAIRE CONTINUED SOCIAL HISTORY- To be completed by all patients Are you currently in school? YES NO Do you have children? YES NO If yes, please provide ages Are you currently smoking cigarettes or using other tobacco products? YES NO Do you drink alcohol? Never Occasionally Daily Do you use drugs? Never Occasionally Daily REVIEW OF SYSTEMS- Please check any problems that you are currently experiencing or have experienced in the last year Gastrointestinal Neurological Cardiovascular Musculoskeletal Endocrinology Nausea Tremors Chest pain Joint pain Cold intolerance Vomiting Seizures Palpitations Joint swelling Heat intolerance Abdominal pain Diarrhea Constipation Blood in stool Memory loss Headache Vertigo Syncope Shortness of breath Dizziness Leg swelling Syncope Leg cramps Muscle cramps Joint stiffness Muscle weakness Excessive urination Excessive thirst Excessive sweating Respiratory Psychological Constitutional Immunology Hematology Cough Wheezing Excessive sputum Shortness of breath Sleep disturbances Disordered eating Anxiety Suicidal thoughts Fever Chills Sweats Fatigue/Malaise Weight loss/gain Insomnia HIV exposure Persistent infections Dermatology Rash Hives Abnormal bruising Abnormal bleeding Varicose veins VITALS- To be completed by all patients Height: Weight: Are you: Right Handed: Left Handed: Have you received the influenza vaccine ( flu shot ) between October-March? YES NO Have you ever been diagnosed with high blood pressure (hypertension)? YES NO The above information is accurate to the best of my knowledge: Patient Signature: Date: Page 6 of 7

7 INFORMATION/FINANCIAL RELEASE FORM- I, HEREBY AUTHORIZE NEW YORK SPINE & PAIN PHYSICIANS TO DISCUSS MY CARE/FINANCIAL INFORMATION WITH, _ at ( ) -. RELATIONSHIP PHONE # THIS INDIVIDUAL WILL BE CONSIDERED YOUR EMERGENCY CONTACT. NAME HIPAA ACKNOWLEDGEMENT- THE PURPOSE OF THIS DOCUMENT IS TO ACKNOWLEDGE THAT I HAVE RECEIVED A COPY OF THE HIPAA PRIVACY ACT FROM THIS OFFICE. I AM AWARE THAT IF I HAVE ANY QUESTIONS REGARDING THIS I CAN CONTACT THE OFFICE MANAGER. MEDICAL INFORMATION RELEASE- I, GIVE NEW YORK SPINE & PAIN PHYSICIANS PERMISSION TO OBTAIN MY PAST MEDICAL HISTORY FROM MY REFERRING PHYSICIAN OR PRIMARY CARE PHYSICIAN. I hereby authorize payment directly to New York Spine & Pain Physicians for services rendered to me and paid by my carrier. I understand that if my insurance carrier does not make payment for these charges I am financially responsible for the charges for services rendered. PRINT NAME *Providing your address authorizes NYSPP to send electronic correspondence to you. You may unsubscribe at any time. Revised DD Page 7 of 7

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