NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE

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Page 1 of 7 DEMOGRAPHICS- To be completed by all patients

Patient Name: _____________________________________________ Today’s Date: ___/____/___

Patient Address: ___________________________________ City: ________ State: ____ Zip: ________ Home Phone #: (____) ____-______ Work #: (____) ____-______ Cell #: (____) ____-______

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

*Email 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 Social Security #: _________________ Insured’s Employer: _______________________ Group #: _____________________ ID #: ____________________ 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?

____________________________________________________________________________________

NEW YORK SPINE & PAIN PHYSICIANS

NEW PATIENT QUESTIONNAIRE

Native Hawaiian

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Page 2 of 7 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: _____________________________________ Phone #: (____) _____-_____ Referring Provider: __________________________________________ Phone #: (____) _____-_____ Cardiologist: ______________________________________________ Phone #: (____) _____-_____ Neurologist: ______________________________________________ Phone #: (____) _____-_____ Pulmonologist: ____________________________________________ Phone #: (____) _____-_____ Endocrinologist: ___________________________________________ Phone #: (____) _____-_____ Other: ___________________________________________________ Phone #: (____) _____-_____

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)

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Chief Complaint (reason for visit): ___________________ Referring Provider: ___________________ Side: Right Left Both

On the diagram, shade in the areas where you feel pain:

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 1 2 3 4 5 6 7 8 9 10

(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?

What activities decrease your symptoms?

What activity would you like to be able to do? _________________________________________________________

Previous conservative measures:

R

L

L

R

R

L

Sitting Walking Standing Bending Lifting

forward Driving Cold/damp

weather Bending backward Coughing/Sneezing

Standing Rest

Sitting Walking Stretching Ice Heat Swimming Avoiding strenuous activity Other: ___________ Other: ___________

NEW PATIENT QUESTIONNAIRE CONTINUED

TELL US ABOUT YOUR PAIN

Patient Name___________________

__Physical therapy __Activity modification __Acupuncture __TENS therapy

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Page 4 of 7 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: _______________________________________________________

Phone #: (____) _____-______

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: ___________

NEW PATIENT HISTORY

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Page 5 of 7 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 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

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 Family Member: _______________Condition: __________________ __Alive __Deceased __Unknown Family Member: _______________Condition: __________________ __Alive __Deceased __Unknown Family Member: _______________Condition: __________________ __Alive __Deceased __Unknown Family Member: _______________Condition: __________________ __Alive __Deceased __Unknown

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Page 6 of 7 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

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: _____________________

Immunology

__HIV exposure __Persistent infections

Dermatology

__Rash __Hives

Cardiovascular

__Chest pain __Palpitations __Shortness of breath __Dizziness __Leg swelling __Syncope

Hematology

__Abnormal bruising __Abnormal bleeding __Varicose veins

Respiratory

__Cough __Wheezing __Excessive sputum __Shortness of breath

Psychological

__Sleep disturbances __Disordered eating __Anxiety __Suicidal thoughts

Neurological

__Tremors __Seizures __Memory loss __Headache __Vertigo __Syncope

Gastrointestinal

__Nausea __Vomiting __Abdominal pain __Diarrhea __Constipation __Blood in stool

Musculoskeletal

__Joint pain __Joint swelling __Leg cramps __Muscle cramps __Joint stiffness __Muscle weakness

Endocrinology

__Cold intolerance __Heat intolerance __Excessive urination __Excessive thirst __Excessive sweating

Constitutional

__Fever __Chills __Sweats __Fatigue/Malaise __Weight loss/gain __Insomnia

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Page 7 of 7  INFORMATION/FINANCIAL RELEASE FORM-

I _________________________________, HEREBY AUTHORIZE NEW YORK SPINE & PAIN PHYSICIANS TO DISCUSS MY CARE/FINANCIAL INFORMATION WITH __________________________________________, ___________________________________ at (____) ____-_____.

THIS INDIVIDUAL WILL BE CONSIDERED YOUR EMERGENCY CONTACT.

____________________________________ __________________________________

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY DATE

 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.

____________________________________ __________________________________

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY DATE

 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.

______________________________ __________________________________

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY DATE

 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.

______________________________ __________________________________

SIGNATURE OF PATIENT OR RESPONSIBLE PARTY DATE

____________________________________________________________________________________________________ _____________________________________________________________________________________________________________________________ _________________________________________

PRINT NAME

*Providing your email address authorizes NYSPP to send electronic correspondence to you. You may unsubscribe at any time.

Patient Name___________________

NAME

RELATIONSHIP PHONE #

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