New Patient Form

Pre-Intake/HPI Form
Welcome to Richmond Spine Interventions and Pain Center! We would like you to know that we appreciate the chance to care for you. Our office is committed to providing you with the highest quality of care possible. We will make every effort to ensure that your visit with us is a comfortable experience. To help you better with your upcoming visit, we need some important information.

Personal Information
Personal Information
Full Name *

First Name Middle Name Last Name
Date of Birth *
mm/dd/yyyy
Email
example@example.com
Do you have any medication allergies? *

Yes No
Please list your allergies and briefly describe the reaction you have:
example: rash, swelling, swelling, difficulty breathing, etc.
Do you have any food allergies? *

Yes No
Please list your food allergies and briefly describe the reaction you have:
example: rash, swelling, swelling, difficulty breathing, etc.
Do you have allergies to IV Contrast or Iodine? *

Yes No
Please explain: *
List your current medications, including any over the counter and dietary supplements with the strength and dosing instructions: (ex: Tylenol 325mg, take 1 tablet 4 times a day as needed) Alternatively, you could bring a list of your medications with you at the time of visit. NOTE: If not applicable, please type "None" or "No Medications" then click "ADD".
List your current medications, including any over the counter and dietary supplements with the strength and dosing instructions: (ex: Tylenol 325mg, take 1 tablet 4 times a day as needed) NOTE: If not applicable, please type "None" or "No Medications". *
You can also upload your medication list

Browse Files

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How tall are you? *
What is your current weight? *
Family Health History
Mother
For other *
Father
For other *
Brother(s)
For other *
Sister(s)
For other *
Maternal Grandmother
For other *
Maternal Grandfather
For other *
Paternal Grandmother
For other *
Paternal Grandfather
For other *
Other
Relationship
For other
For other *
Social History
Tobacco Status *
How much do you smoke? *
For Other *
Comment
When did you stop smoking?
Approximate month/year
Have you ever used smokeless tobacco? *
How long have you used tobacco products?
Comment
Have you ever used e-cigarettes or vapes? *
Comment
How often do you drink alcohol *
How long have you been consuming alcoholic beverages? *
Have you ever used illicit drugs? *
Please explain
Have you ever had a problem with substance abuse? *
Please explain
Are you currently employed? *

Yes No
What is your occupation? *
What is your employment status? *
Other
Are you disabled? *

Yes No
Are you retired? *

Yes No
Is this a work-related injury? *

Yes No
Approximate month and year of injury and brief description:
Have you experienced a similar pain complaint prior to this injury?
Is this an auto accident-related injury? *

Yes No
Approximate month and year of injury and brief description:
Have you experienced a similar pain complaint prior to this accident?
Do you have difficulty walking or climbing stairs? *

Yes No
Do you live alone or with others? *

Live alone With others
With Others:
Relationship
Marital Status *
Number of Children *
Past Surgical History

Please select surgical procedures you've had in the past with their approximate dates and the names of the performing surgeons, if known:

Select

Approximate Date

Performing Surgeon

Appendectomy

Tonsillectomy

Gallbladder surgery

Knee surgery

Back surgery

Neck surgery

Hysterectomy

Cesarean section

Please list any other surgical procedures you've had in the past with their approximate dates and the names of the performing surgeons, if known:
approximate month and year
Past Medical History
Have you ever had a Mammogram? *

Yes No Not Applicable
Approximate month and year of Mammogram
Have you ever had a Colonoscopy? *

Yes No Not Applicable
Approximate month and year of Colonoscopy
Have you had a Flu Vaccine in the past 12 months? *

Yes No
Approximate date of Flu Vaccine
Have you had a Pneumonia Vaccine in the past 12 months? *

Yes No Not Applicable
Approximate month and year of Pneumonia Vaccine
Past Medical History: *

AIDS/HIV Acid Reflux (GERD) Anxiety/Depression Arthritis Asthma Bleeding Disorder Cancer COPD Coronary Artery Disease Diabetes Fibromyalgia Gout Heart Attack (MI) Heart Disease Hepatitis Hyperlipidemia Hypertension Kidney Disease Liver disease Lupus Osteoperosis Rheumatoid Arthritis Seizures Stroke Thyroid Problems Ulcers None Known
What type of cancer?
Are you Left or Right Handed? *

Right Left Both

History of Present Illness
History of Present Illness
Chief Complaint (Reason for visit) : ex. Back Pain
Where is the exact location of your pain today? *
You may also help us visualize the location of your pain by shading the body part in the image provided below.
Does your pain radiate into your Arm(s) or Leg(s)? *

Yes No
Where does your pain radiate into? *

Right Arm Left Arm Right Leg Left Leg
Please describe how your pain radiates
Ex. Pain radiates in right leg below the knee.
Approximate month & year the pain started *
In your opinion, can you specify any events that could have caused your pain? Please describe the event briefly (with approximate date): *
Which of the following activities are you not able to perform? *

Activities of daily living (ADLs) Work School Home duties Sleep Recreational activities No functional impairment
Do you experience any of the following? *

Numbness Tingling Weakness None of the above
Location where you experience the above symptom(s): *
When is your pain worse? *

Mornings Afternoons Evenings Night My pain is the same all the time None of the Above
What makes your pain worse? *

Sitting Standing Bending None of these
What makes your pain better? *

Lying Down Sitting Standing Walking Bending Medications None of these
How would you describe your pain? *

Burning Sharp Aching Deep Annoying Gnawing Stabbing Cramping Shooting Throbbing
On a scale of 0-10, 0 being no pain and 10 being the worst pain you can imagine.

Describe your pain at its worst: *

	0	1	2	3	4	5	6	7	8	9	10

0 is No Pain, 10 is Worst Pain

Describe your pain on average: *

	0	1	2	3	4	5	6	7	8	9	10

0 is No Pain, 10 is Worst Pain

Describe your pain at its worst: *

0 1-3 4-6 7-9 10
Describe your pain on average: *

0 1-3 4-6 7-9 10
Describe your pain at its least: *

0 1-3 4-6 7-9 10
Describe your pain at its worst: *

0 1 2 3 4 5 6 7 8 9 10
Describe your pain on average: *

0 1 2 3 4 5 6 7 8 9 10

Medications
Medications
Have you taken any over-the-counter medications to treat your pain? Example: acetaminophen, Aleve, Advil... *

Yes No
Please list down these over-the-counter medications:
Please list down these over-the-counter medications
Have you taken any prescription medication for your pain? *

Yes No
Please list down these prescription medications:
Please list down these prescription medications, approxiamte date tried(mm/yy), approximate relief(ex.50%), still using these meds?(y/n):

Other Treatment Modalities
Other Treatment Modalities
Have you tried TENS unit for this pain? *

Yes No
Are you currently using a TENS unit? *

Yes No
Approximate date tried *
month/year
# of weeks tried *
Approximate % of relief *
Have you tried heat for this pain? *

Yes No
Approximate date tried *
month/year
# of weeks tried *
Approximate % of relief *
Have you tried ice for this pain? *

Yes No
Approximate date tried *
month/year
# of weeks tried *
Approximate % of relief *
Other Treatment modalities you have tried
ex.Iontophoresis, Ultrasound, Phonophoresis, Electrical Stimulation, etc.

Procedures and Surgical Interventions
Procedures and Surgical Interventions
Have you tried spinal injection(s) for this pain? *

Yes No
Spinal Injection(s) *
Have you had spine surgery for this pain? *

Yes No
Approximate date of surgery *
Type/Body location of surgery (if known)
Ex. Left Knee Surgery
Name if Doctor (If known)
% of relief *
Ex. 80 % relief, 100% relief or no relief
Duration of relief *
Ex. 2 Weeks

Imaging
Imaging
Please list any of the following imaging studies in relation to this pain:
Have you had MRI Scan for this pain? *

Yes No
Region of the body where MRI was performed
(Ex. Neck, back, head, hips, legs, foot, etc.)
Approximate month & year and the name of the facility where MRI was performed: *
Approximate month & year and the name of the facility where MRI was performed:
Have you had CT Scan for this pain? *

Yes No
Region of the body where CT Scan was performed
(Ex. Neck, back, head, hips, legs, foot, etc.)
Approximate month & year and the name of the facility where Ct Scan was performed: *
Approximate month & year and the name of the facility where CT Scan was performed:
Have you had X-ray for this pain? *

Yes No
Region of the body where X-ray was performed
(Ex. Neck, back, head, hips, legs, foot, etc.)
Approximate month & year and the name of the facility where X-ray was performed: *
Approximate month & year and the name of the facility where X-ray was performed:
What are your expectations for your visit?

New Patient Evaluation Agreement
New Patient Evaluation Agreement
I understand that I will have an evaluation by a provider at Richmond Spine Interventions and Pain Center. The provider will perform an evaluation, a physical examination, and review some of my medical records. This evaluation may or may not consist of possible treatments, including referrals, prescription medications, and procedures. The provider will make recommendations based upon this evaluation, which may or may not include future treatment at Richmond Spine Interventions and Pain Center. I understand that there will be a charge submitted to my insurance company and I will be responsible for my copayment at the time of my visit, and my deductible as per my insurance plan policies. *

I agree I disagree
NOTE: For the signature

For Computer users: You may use your mouse by holding down the left click button and use it like a pen signing on a paper make sure you are not going outside the signature box when signing.

If Using Mobile: Use your finger as a pen to sign inside the box and make sure you are not going outside the signature box when signing.
Signature
Date

Month Day Year
Date

Submit Form
You may click "Save" to save the form and continue later or you may click "Submit" if you are done.

NOTE: Upon submitting the form, please wait until you reach the "Thank You" page before exiting.

If you have trouble submitting this form, DO NOT exit out of this form and call our office at 804-378-1800 for assistance. (if you're calling after office hours, please leave a message and we will get back to you as soon as possible)
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Pre-Intake/HPI Form

Personal Information

Family Health History

Social History

Past Surgical History

Past Medical History

History of Present Illness

Medications

Conservative Treatments

Other Treatment Modalities

Procedures and Surgical Interventions

Imaging

New Patient Evaluation Agreement